I Have done it. please need help to read over and make corre
I Have done it. please need help to read over and make correction… I Have done it. please need help to read over and make correction it needed. the concept direction is at the bottom. Engage FundamentalsEliminationClinical Judgment Case Study with Concept MapCase study A 25-year-old woman who is at 34 weeks’ gestation arrives to the obstetrician’s office for her routine appointment; she is accompanied by her husband. The client informs the nurse that she has some generalized abdominal discomfort and has had firm stools recently that are hard to pass and less frequent than usual. Additionally, the client reports urine leakage that is especially noticeable with coughing, laughing, or sneezing. The client reports managing the symptoms of constipation with increased fluid intake but no other measures. The provider examines the client and determines the client demonstrates an otherwise normal assessment. The provider instructs the nurse to provide the client with directions on constipation management, including an over-the-counter stool softener and urinary incontinence related to pregnancy.Patient’s age: 25 years oldPurpose of Vitiation: Routine appointment, 34 weeks’ gestationFamily Member Present: Patient Husband.Nursing Diagnosesconstipation and urinary leakage which can be due pregnancySubject DateClients inform about generalize abdominal discomfort Firm stool Object DataConstipationUrine leakageAssessmentProblemPlanning/GoalsInterventionSubjective:Clients inform about generalized abdominal discomfort.Objective:ConstipationUrine leakage 1.Abdominal discomfort related to firm stool that are hard to pass. 2. Constipation related to pregnancy. 3.Urine leakage related to pregnancy. 1.After 8 hours of nursing intervention, the client will verbalize relief from pain. 2.After 8 hours of nursing intervention, the client will return to normal pattern of bowel elimination.3.After 8 hours of intervention the client will verbalize relief from urinary incontinence. 1.Assess and auscultate bowel sound.Advise to avoid gas forming foods.Give stool softener as ordered.2.Provide health teaching regarding use of stool softener.Advise to eat foods high in fiber.3. Educate the client about Kegel exercise to strengthen the pelvic floor muscle.Advise to avoid caffeine intake. Patient’s Priority from most urgent to less urgent.Abdominal discomfort related to firm stool that is hard to pass should be priority one because abdominal discomfort can cause pain, bloating, cramps, gas. This would cause client to be restless, fever and more.Constipation related to pregnancy would be our second priority. This is cause by progesterone, the fetus growing, iron from prenatal vitamin and lifestyle. Urine Leakage related to pregnancy would be our third priority. Urine leakage is common during pregnancy because the bladder can be place under presume. This is not life threating but can cause discomfort in most pregnancy woman. Client ProblemInventionPotential Client Intervention Evaluation ImprovementPotential client intervention Evaluation WorseningPotential Client worsening evaluation Reassessment.Abdominal discomfort related to firm stool that are hard to pass. Assess and auscultate bowel sound.Advise to avoid gas forming foods.Give stool softener as orderAfter stool softener was given, client had a bowl movement within 15 munities. clients show sign of relief from all pain, cramps, and bloating, after 8 hours.After stool softener was given, client complain of feeling more pain and was still having difficulties with bowl movement.The Nurse should reassess client by auscultate for bowl sound and report finding to provide for another method that would help with bowl movement. Constipation related to pregnancy. Provide health teaching regarding use of stool softener.Advise to eat foods high in fiber. After 8 hours client shown sign of relief, client was laying with no complain of pain or discomfort. Client ate more of fiber food as advise and client bowl movement was improved.After 8 hours, client complained pain, cramps, and gas. Client stated that she is still having constipation. The nurses should apply another stool softener, report finding to provider, and observe client every 30 minutes to see if there would any sign of relief. Urine leakage related to pregnancy Educate the client about Kegel exercise to strengthen the pelvic floor muscle.Advise to avoid caffeine intake. After 8 hours, client show no sign of urine incontinence. After 8 hours, client complain of still having urine incontinenceThe nurse should reassess the client and teach the client the Kegel exercise and avoidance of coffee. The nurse should ask the client to report improvement or changes after a week. DIRECTION NURS 304 Concept Map/Care plan Concept map diagrams enable visualization of interrelationships between medical diagnosis, nursing diagnosis (client problems), assessment data, and treatments. Step One -Develop Basic Skeletal Diagram Use the Engage Fundamentals clinical judgement case study concept map structural framework. Indicate admitting diagnosis. Under assessment information, write down all pertinent client information (objective and subjective data) from the scenario notably: age, gender, past medical history, allergies, labs/diagnostics, VS with pulse ox, pain and any other subjective data, activity/functional level, elimination status (bowel and urinary), diet, socio-cultural, spiritual data as applicable Step Two – Analyze & Categorize Data (Assessment Data – Objective & Subjective). In this step you should analyze and categorize assessment data gathered from the clinical judgement case study scenario or patient’s medical records (introduction) and your brief encounter with the patient if in clinical or simulation. Within each of the 3 client problem boxes, based on the validated and analysis of assessment data indicate in order of priority client’s actual or potential problems (complications). Note: Problems should be nursing diagnosis (client problems) not medical diagnosis. Step Three: Identify Goals and interventions This step corresponds to the planning phase of the nursing process. Goals are client responses that would demonstrate improvement of the problem by discharge. Within each client problem box, identify one goal and three interventions for the treatment of the identified problem. Note: In actual patient setting, these interventions will be implemented by the nurse to achieve stated goal. Indicate rationale for each intervention. Remember that both goal and interventions should meet SMART criteria. Ensure action verbs. Step Four: Evaluate Patient Responses For each of the client problems: a. Write potential client response(s) that demonstrate an improvement of each stated problem. b. Write potential client response(s) that indicate worsening of each stated client problem c. Write further nursing actions for each of the potential client response(s) that indicate worsening of the client problemHealth Science Science Nursing NURS 304
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