Normal delivery Please complete a Problem Based Care Plan and Concept Map for Vaginal Delivery

What assessment data does the nurse find as pertinent (important) (recognize cues)?

Risk factors: Laticia Garcia, a 15-year-old female, has not received prenatal care due to pregnancy denial, current weight 158lbs, which is slightly lower, nulliparity, and sexually active.

Current problem: The patient complains of excruciating abdominal pain has a distended abdomen. Lab results includes Na: 142, K: 4.2, Plt: 265, Hgb: 13, Cl: 102, Mg: 1.2, and WBC: 5.2. The majority of the lab results are within the normal range, therefore eliminating the possibility of infections or systemic diseases. For example, WBC: 5.2 is within the normal range; therefore, it is unlikely that the patient has any infections. The Mg:1.2 is, however, slightly lower than the normal range of 1.8, which suggests the possibility of a health condition; however, since other parameters are within the normal range, it is less likely that the patient has an underlying condition. The distended abdomen and excruciating pain suggest the possibility of a pregnancy, which can explain the slightly lower mg levels since the patient has not had prenatal care (Liu & Zhang, 2021).

What is the disease process causing these assessment findings?

Full-term pregnancy: The primary diagnosis for this patient is a full-term pregnancy which is not a health condition; rather, it is a normal biological condition that results in the birth of a child. A full-term pregnancy is defined as a pregnancy where the baby is born between 39 weeks 0 days to 40 weeks 6 days. The excruciating abdominal pain experienced by the patient is labor pains. At the end of a pregnancy, uterus contractions occur to push the baby out, leading to pain as the muscles tighten. At the end of pregnancy, the body will start to produce hormones such as prostaglandin, which increases the sensitivity to other hormones. Oxytocin contributes to contractions that facilitate the expulsion of the fetus, relaxin, and Beta-endorphins facilitate stretching of the cervix and relief from pain, respectively (Tripp, 2021).

What is the main problem with the patient the nurse can treat?

Pain management relief measures will be necessary for this patient. The care provider should initiate natural pain relief measures such as patterned breathing, movement, and position changes. Medications can also be used to manage the pain. The patient is in denial of pregnancy; therefore, care provider should inform the patient and the family members of the pregnancy status and explain to the patient that she is pregnant and that it is due for delivery, which should explain the excruciating abdominal pain (Nanji & Carvalho, 2020).

What is the goal for the patient outcomes?

• The patient and the family members will be aware of her pregnancy status.
• The patient will experience pain relief during the delivery process.
• The patient will have a natural birth with minimal complications.

What interventions will the nurse implement when caring for this patient

• Assess the patient’s psychological readiness; it is important to ensure that the patient is psychologically aware and ready for the birth process, including the actions that are necessary to have a safe delivery, dangers and risks associated with the birth process, and the impact the delivery process will have on her physically and emotionally.
• Allow and encourage the patient to be active: research has shown that assuming upright positions during labor is effective in preventing complications associated with delivery.
• Assess the patient’s vital signs and those of the fetus; this will assist in detecting any abnormalities early enough to prevent complications.
• Conduct patient education on the delivery process and after delivery care practices; patient education will ensure that the patient is aware of the delivery process and can identify abnormalities such as excessive pain; it will also equip her with the necessary skills and knowledge to handle emergencies (Nanji & Carvalho, 2020).

How will the nurse evaluate the patient’s response?

• The patient will report a decreased level/severity of labor pains.
• The patient will exhibit increased awareness concerning her pregnancy and the necessary measures to be taken in the event of an emergency.
• The patient will maintain normal vital signs as well as the fetus.

What other problems could the nurse link to this patient problem?

Some of the conditions that can cause excruciating abdominal pain include organ rupture, including appendicitis, kidney stones and infections, irritable bowel syndrome, u

Order this paper