Admission Physical Assessment
Temp. 37C, P 80, BP 150/102, R 18. (lungs clear to auscultation)Baseline fetal heart rate per continuous external monitoring: 122; no accelerations,minimal baseline variability, questionable subtle late deceleration with rare uterinecontractions of mild intensityCervical exam: 1-2 cm. Dilated, minimally effaced, vertex at –1 station.Membranes intactDeep tendon/patellar reflexes: 3+Pain: Headache since 3 AM pain scale 3/10; no epigastric painEdema: 3+ pretibial; patient reports face “puffy” since 2-3 days ago
Step 1: Choosing the Nursing Diagnoses
include, but may not be limited to, the following:
Nursing Diagnosis: Childbearing, maladaptive: antepartum/intrapartum status
There is a deviation from physiologic adaptive changes thatsupport the health of mother and/or fetus during pregnancy
Maternal vascular compromise related to long-term diabetesexacerbation of maternal carbohydrate intolerance/insulinresistance related to Type I diabetes of long duration
Fetal compromise secondary to decreasing placental function
Nursing Diagnosis: Risk for altered parenting
Risk for inability of the primary caretaker to create, maintain,or regain an environment that promotes the optimum growthand development of the child.
Physical illnessFor purposes of working through this exercise, the second diagnosis,
Risk for Altered Parenting
On the nursing careplan form, write in the nursing diagnosis, the defining characteristics & relatedfactors.