Step #1: THINK Like a Nurse by Recognizing RELEVANCE and PRIORITIES
Michelle Moore 38yr old
Four Principles of Clinical Reasoning:
1. Identify and ... [Show More] interpret RELEVANT clinical data.
2. TREND relevant clinical data to determine current status (stable vs. unstable).
3. Grasp the “essence” of the current clinical situation.
4. Determine nursing PRIORITY and plan of care.
History of Present Problem:
Michelle Moore is a 38-year-old who is 29 weeks pregnant. She began prenatal care at 18 weeks gestation because she was waiting to become insured. She is currently being seen in the Labor and Delivery Unit of the hospital following a call to her health care provider in which she stated she has had constant uterine pain she rated at 6/10 accompanied by vaginal bleeding and decreased fetal movement the past several hours.
Past Medical History Home Meds:
• Gravida 4, Para 1 with a partial abruption at 38 weeks
• Menses began at age 12, are usually 29 days apart, lasting for 4-5 days, with moderate-to-light flow.
• Successfully breast fed her first child for 11 months.
• Vaccinations are up to date.
• Michelle is biracial: African American and Asian, and she was tested for sickle cell trait. Lab results reveal
Michelle is a carrier of the trait. It is unknown if the father of the baby is also a carrier. 1. Prenatal vitamin 1 tab PO daily
2. Acetaminophen 650 mg PO PRN every 4 hours for infrequent, mild headaches
What data from the PRESENT PROBLEM are RELEVANT and must be interpreted as clinically significant by the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
• Advanced maternal age
• 29 weeks gestation
• Delayed prenatal care
• Experiencing uterine pain and vaginal bleeding with decreased fetal movement
• Previous abruptions
• Sickle cell trait carrier • Risk factor for placental abruption
• Baby is not term yet, need to be aware of possible resources to resuscitate baby when it is born
• Delayed care to fetus and decreased amount of monitoring risk for unnoticed complications
• Signs commonly found in placental abruption fetus could not be getting what it needs such as O2 and nutrients
• Very big risk factor for experiencing placental abruption again
• History of complicated pregnancies
• If dad is also a carrier, baby could be affected for hemodynamic
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