MHIERSALYN A.

MIRUL BSN 2

CASE SCENARIO:

Activity:

1. From the case provided, you were asked to chart using FDAR (charting) based on case
presented.
2. Using your TPR sheet, plot the vital signs provided.
3. Make a Nursing Care Plan for patient J.A.

Time: 8:00am ( Taken at OB ER)

Vital signs: PP- 98, RR- 23 Temp. 36.7 BP 120/70

Time: 11:45nn

You were working at Labor and Delivery Complex in Arellano Hospital for 5 years. While doing
you rounds a patient from the OB ER was transferred to your unit. While waiting for other
papers to be endorsed, you review the patient chart, revealing the following:

Patient J. A. , admitted 4 hours ago, is a 30-year-old gravida 3 para 1-0-1-1 married woman
whose expected date of delivery is today. Her first prenatal visit was at 12 weeks and she had
10 visits total. Patient J. A. lab work includes:

 Hemoglobin: 12g/dL
 Blood type: A negative
 VDRL: non-reactive
 Urinalysis: normal
 Rubella titer: 1:10
 Hepatitis B screen (HbsAg): negative
 HIV screen: negative
 Pap smear: Negative

Significant information:
 Patient J.A. Pre-pregnancy weight was 60kg.
 Her baseline blood pressure was 110/64, BP’s remained 110-120/64-70 throughout her
pregnancy.
 Her routine urine samples were normal and her chart reveals normal fetal growth throughout
her pregnancy.
 She had 2 ultrasounds and did not want to know the sex of her baby.
 JA had a glucose screen at 24 weeks with a plasma glucose level of 110 mg/dL.
 Her Group B strep screen at 36 weeks was negative.
 She remained healthy and active and medications included only prenatal vitamins
daily.

Time: 12:00nn
During your admission you gathered the following:
 JA cervix was dilated to 6 cm and 80% effaced, at a zero station.
 The baby’s position is ROA.
 Spontaneous rupture of membranes occurred at home 6 hours ago, fluid was clear.
 JA is having strong contractions every 2 minutes, lasting 60 seconds.
 Fetal heart tones are 140-150 with good variability.
 Vital signs: PR – 90, RR – 20, Temp – 36.2, BP – 122/72.
 She has an IV of LR in her right arm that is saline locked.

She and her husband are using their breathing techniques and managing the
Contractions well. They are really pleased that they did not have to be induced again like last
time. JA hopes to have a natural childbirth without the use of drugs, which she also
accomplished with her first delivery. She did relate that her contractions seem stronger this
time and she may be rethinking that decision.

Time: 4:00pm

As you prepare to do rounds, his husband runs out of the labor room and is clearly upset and
anxious. He yells: “You need to hurry, she wants something for pain and she says she feels
like pushing.

Vitals signs: PR – 95, RR – 28, Temp – 36.8, BP – 130/80.

Upon assessment JA is now completely dilated and she has been Pushing for ten minutes. The
baby is crowning. The FHT is 130- 140 bpm from a 140bpm baseline with each contraction.

You decided to direct her to the delivery room and the doctors and nurses were notified.

Time: 4:30pm

JA delivers a baby boy who is immediately placed on her abdomen. His APGAR score
are 8 at one minute and 9 at five minutes. The other nurse cut the cord on time and you
waited for 10 minutes for the placenta to be delivered. The baby is awake and JA wants to
know if it is too soon to breastfeed. Immediate care of the newborn was carried and attended.

Time: 8:00 pm ( Taken at OB Ward)

Vital signs: PR 89, RR 20, Temp – 36.9 BP- 110/80

 Date/Hour Focus Progress Notes
Labor pain D: “You need to hurry, she
Time: 4:00pm wants something for pain and
she says she feels like pushing.”
As verbalized by the
husband.
Pain scale of 8 out of 10
 Facial grimace

 Guarding act

Vitals signs: PR – 95, RR – 28,

Temp – 36.8, BP – 130/80.

A: Administered pain
reliever medication 500mg.

Encouraged deep
breathing exercises and
relaxation techniques.
Kept patient comfortable
and safe.

R: the mother was able to

Time: 8:00 pm effectively deliver a healthy
baby and the labor pain is
manageable with pain
scale of 5 out of 10.