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DRLR Guided Questions

1. Before beginning the assessment of Mrs. A, establish rapport by introducing yourself and explaining the assessment process. Gather baseline information by taking vital signs and asking questions about her pregnancy, health history, and any previous pregnancies. 2. Include questions about Mrs. A's history of miscarriages, stillbirths, early infant death or other health conditions, as these can increase risks during pregnancy. 3. The physical examination of Mrs. A should include observation of behaviors, taking vital signs, measuring fundal height, Leopold's Maneuver, listening for fetal heart tone, and cervical examination to monitor the pregnancy.

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71 views1 page

DRLR Guided Questions

1. Before beginning the assessment of Mrs. A, establish rapport by introducing yourself and explaining the assessment process. Gather baseline information by taking vital signs and asking questions about her pregnancy, health history, and any previous pregnancies. 2. Include questions about Mrs. A's history of miscarriages, stillbirths, early infant death or other health conditions, as these can increase risks during pregnancy. 3. The physical examination of Mrs. A should include observation of behaviors, taking vital signs, measuring fundal height, Leopold's Maneuver, listening for fetal heart tone, and cervical examination to monitor the pregnancy.

Uploaded by

Reyjan Apolonio
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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1. Before beginning your assessment, what should you do for and ask Mrs. A?

ASSSESSMENT
(information gathering through history, physical examination, and testing)
- Before beginning assessment, I have to establish rapport with the patient like introducing
myself, explaining what I will be doing during the assessment and why. Followed by getting
the basic vital signs including blood pressure, heart rate, respiratory rate, and height and
weight of the patient.
Questions to ask:
- How is your pregnancy going? How are you feeling?
- Is this a good timing for your pregnancy?
- Have you had any changes in your appetite or sleep habits?
- Is this your first pregnancy?
- How long have been pregnant?
- How many times have you been pregnant?
2. What history will you include in your assessment of Mrs. A and why?
- Have any of your child been miscarriages, stillbirth, or early infant death? Women with a
previous miscarriage were at higher risk of threatened miscarriage and preterm delivery.
- Do you have any health problems or medical conditions not related to pregnancy? Increase
the chance of your having a miscarriage or your baby being born too early.
3. What physical examination will you include in your assessment of Mrs. A and why?
- Observe the patient. Grimace or actions.
- Get the vital signs of the patient. Respiration rate, heart rate, blood pressure, and
temperature.
- Get the fundic height.
- Leopold’s Maneuver
- Get the fetal heart tone of the baby.
- Cervical examination
4. What laboratory tests will you include in your assessment of Mrs. A and why? DIAGNOSIS
(interpreting information to identify problems/needs)
- Blood sample, urine sample or sample of tissue taken from your vagina, cervix, or rectum.
These tests can help find conditions that may increase the risk of complications for you and
your fetus.
- RPR (rapid plasma reagin) is a screening test for syphilis. It measures substances (proteins)
called antibodies that are present in the blood of people who may have the disease.
- Doctors recommend all pregnant women get tested for HIV. Medications are available to
prevent the spread of the virus to your unborn baby.
5. Based on these findings, what is Mrs. A's diagnosis (problem/need) and why? CARE PROVISION
(implementing plan of care and interventions)
- Labor pain related to uterine contractions and stretching of cervix and birth canal as
evidenced by patient’s verbalization of pain radiation from back to front.
- Because she repeatedly states that labor was more painful than she had expected. Also, she
reports a pain that start in her back and move forward, last 20 seconds, and occur about
every 8 minutes.
6. Based on your diagnosis (problem/need identification), what is your plan of care for Mrs. A. and
why?
- As a healthcare provider, I want my patient to feel more relax and demonstrate deep
breathing exercises. I want my patient to identify and use methods in controlling pain. Pain
is the priority of care that’s why I have to investigate reports of pain, monitor vital signs and
note non verbal cues, provide a quiet environment and reduce stressful stimuli, positioning
the patient in a comfortable position, and I will provide comfort measures, such as massage
and cool packs.
- Helpful in assessing need for intervention and may indicate developing complications.
- May be useful in evaluating verbal comments and effectiveness of interventions.
- Promotes rest and enhances coping abilities.
- May decrease associated bone and joint discomfort.
- Enhances effects of medication.
7. Based on these findings, what is your continuing plan of care for Mrs. A and why?
- Based in these findings, I want my patient to report anxiety reduced and/ or manageable. I
will be by her side and talk about feeling anxious. I will help my patient to walk because
moving our body is one of the most recommended ways to manage stress. I will help my
patient to have a deep breathing exercise for 20- 30 minutes because it will help provide
more oxygen to patient’s brain and stimulate nervous system. I will ask my patient to sleep
because getting enough sleep may help significantly with her anxiety symptoms.

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