NUR 3330 Stephanie Gold Room 303 Med-Surg (ALL EVALUATIONS)
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Course
NUR 3330 Stephanie Gold Room 303 Med-Surg
Institution
Harvard University
NUR 3330 Stephanie Gold Room 303 Med-Surg (ALL EVALUATIONS)
Stephanie Gold, 19-year-old Caucasian female, G1 T0 P0 A0 L0, 32 weeks gestation. Uncomplicated
pregnancy except for anemia treated with PO iron. States 3 times in last week has called on-call
obstetrician about fatigue, body aches, mi...
NUR 3330 Stephanie Gold Room 303 Med-Surg (ALL
EVALUATIONS)
Stephanie Gold Room 303
Stephanie Gold, 19-year-old Caucasian female, G1 T0 P0 A0 L0, 32 weeks gestation. Uncomplicated
pregnancy except for anemia treated with PO iron. States 3 times in last week has called on-call
obstetrician about fatigue, body aches, mild nausea during the evening. The client reports, “I don’t feel
well, I haven’t vomited, but nausea makes me not want to eat too much. I am drinking ok, just want to eat
bland foods.” Rest and acetaminophen were recommended. Client is first-year nursing student and states
several students have had a “GI bug”. States during day felt better and went to school all but one day. No
fever. She stated: “Can’t be absent from nursing school!” No contractions, leaking of fluid or vaginal
bleeding. Came in this morning (Saturday) due to pain by right rib cage. States this is new today. Boyfriend
accompanies client.
You responded correctly to 5 out of 6 evaluations:
Category Your response Explanation
Educational Needs Increased acuity Status Assessment reports r/t change in condition
Fall Risk Normal acuity Status Assessment reports r/t physiological shifts of pregnancy/center of gravity
, Category Your response Explanation
Health Change Increased acuity Status Assessment reports r/t malaise/nausea/pain during pregnancy
Pain Level Increased acuity Status Assessment reports r/t right upper quadrant pain
Psychological Needs Increased acuity Status Assessment reports r/t concern about her baby’s health/her health and absence from nursing school
Sensorium Normal acuity Status Assessment reports no indication in report that there is a change in sensorium
Physiological
Your
Description Response Explanation
Deficient Fluid True Status assessment reports no generalized edema from fluid shift from intravascular to extravascul
Volume assessment/nausea not significant enough to cause deficit.
Imbalanced False Status assessment reports assessments do not show nutrition has been substantially impacted by
Nutrition nausea.
Injury, risk for True Status assessment reports r/t risk for uteroplacental insufficiency secondary to vasospasm if abdo
fetal pain and malaise/elevated BP indicate preeclampsia/HELLP syndrome.
Injury, risk for True Status assessment reports r/t hypertension and vasospasm and potential decreased renal perfusio
maternal
Nausea True Status assessment reports experiencing slight nausea off and on this week.
Safety
Your
Description Response Explanation
Fall Risk True Status assessment reports r/t shifting center of gravity at 32 weeks gestation and in the t
trimester.
Injury, risk for True Status assessment reports r/t risk for worsening preeclampsia to eclampsia and seizures.
maternal
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