lOMoAR cPSD| 10631844
Shadow Health Non-Reassuring Fetal Status Subjective Data
lOMoAR cPSD| 10631844
| Shadow Health® │ Digital Clinical Experiences™ from Elsevier
Focused Exam: Non-Reassuring Fetal Status Results | Completed NURS 438: Patient-Centered Care: Childbearing Family Fall 2022, NURS 438 Return to Assignment (/assignments/673643/)
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Overview
Subjective Data Collection: 28 of 34 (82.4%)
Transcript Subjective Data Collection Hover To Reveal...
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Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
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Objective Data Collection Education & Empathy Documentation Care Plan Intervention Activity
Category
Scored Items
Student Survey
Patient Data Not Scored
Experts selected these topics as essential components of a strong, thorough interview with this patient.
A combination of open and closed questions will yiel better patient data. The following details are facts of t patient's case.
Patient Status
Asked about patient's needs
Reports needing support person with her Reports partner went to meet patient's mother
Patient Comfort
Asked about patient's comfort
Reports current position is comfortable
Asked about patient's symptoms
Reports dull contraction pain Reports feeling contractions starting in upper abdomen
Followed up on pain
Reports contraction pain 5 out of 10
Asked about relieving factors
Reports using "yoga breathing" during contractions
lOMoAR cPSD| 10631844
| Shadow Health® │ Digital Clinical Experiences™ from Elsevier Reports movement helps alleviate pain
Review Birth Plan
Asked about birth plan
Denies wanting to use pain medication Reports desire to use birthing tub Reports desire for support person to be present at delivery
Followed up on pain management preferences
Reports desire to use essential oils during active labor and delivery Reports desire to use "yoga breathing" during active labor and delivery Reports plan to use position changes during active labor and delivery
Followed up on support system
Reports support person is partner, Javier
Asked about infant care
Reports planning to breastfeed
Asked about contraction time
Reports contractions 5 minutes apart
Intranatal History
Reports contractions 1 minute in duration
Asked about current pregnancy
Reports current pregnancy is overdue (40 weeks 2 days) Reports water has broken
Followed up on water breaking
Reports water broke in OB office during appointment Reports amniotic fluid clear Reports amniotic fluid odorless Reports OB appointment was to discuss inducing labor
Asked how she was transported to the hospital
Reports partner drove her from OB office to hospital
Asked how long she has been in labor
Reports laboring for 7 hours
Asked about prenatal care
Reports taking prenatal vitamins Reports receiving prenatal care starting at 8 weeks
Asked status of baby
Reports baby moving daily
Asked about vaginal discharge
Reports vaginal discharge Reports vaginal discharge is clear Denies vaginal bleeding Denies unusual odor for vaginal discharge
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lOMoAR cPSD| 10631844
| Shadow Health® │ Digital Clinical Experiences™ from Elsevier Reproductive History
Asked about previous pregnancies
Reports two previous pregnancies
Followed up on first pregnancy
Reports first pregnancy was 39 weeks Reports delivering healthy baby boy Reports she was in labor for 17 hours Reports first birth was vaginal Denies use of pain medication during first birth
Followed up on second pregnancy
Reports second pregnancy was 40 weeks Reports delivering healthy baby girl Reports she was in labor for 8 hours Reports second birth was vaginal Denies use of pain medication during second birth
Asked about pregnancy complications
Denies pregnancy complications Denies sudden weight gain
Social History
Asked about home life
Reports longterm partner, Javier Reports one son, Junior Reports one daughter, Genesis
Followed up on children
Reports Junior is 10 years old Reports Genesis is 5 years old Reports children are staying with paternal grandparents
Asked about substance use
Denies illicit substance use Denies alcohol use Denies tobacco use
Past Medical History
Asked about preexisting conditions
Denies diabetes Denies hypertension
Asked about allergies
Denies allergies
Asked about past hospitalizations
Reports only hospitalized for past pregnancies
Asked about anesthesia
Denies complications with anesthesia
Asked about patient's home medication
Denies taking prescription medications
Home Medication
Reports taking herbal supplements
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lOMoAR cPSD| 10631844
| Shadow Health® │ Digital Clinical Experiences™ from Elsevier Review of Relevant Systems
Asked about gastrointestinal system
Denies nausea Denies indigestion Denies sharp stomach pain
Asked about urinary system
Denies needing to urinate
Asked about respiratory system
Denies shortness of breath
Asked about neurological system
Denies dizziness Denies having headache Denies vision changes
Asked about cardiovascular system
Denies cardiovascular issues
Comments If your instructor provides individual feedback on this assignment, it will appear here.
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