Case Overview Graciella Question & Answer Guide (With Explanation)
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Original Question
Case Overview: Graciella Muñez is a 24-year-old female with a history of oligomenorrhea. She has had a preconception work-up completed with the results showing possible polycystic ovarian syndrome (PCOS). Since her initial work-up she has lost 20 pounds and has arrived at her 3-month follow-up appointment with a positive pregnancy test. DocuCare Activity/Assignment Prep: Review the Clinical Decision Support Tool (Green Lippincott Advisor links) provided throughout your patient’s chart: Pregnancy (first trimester, normal) O’Meara, A. Graciella Muñez. Maternity, newborn, and women’s health nursing: A case-based approach. Philadelphia, PA: Wolters Kluwer. Review chart including Patient Information, Maternity, Notes, Assessments, Diagnostics, Vital Signs, and Orders Activities/Assignments: Part One: The healthcare provider has asked you to obtain Ms. Muñez’s weight, a finger stick glucose and complete the patient’s family medical history in the electronic health record (EHR). Assignment 1.1: Document the following findings in Ms. Munez’s EHR: Family History (Patient Info > Admission Assessment > Family Health History): Hypertension, Father, onset at age 50, still living Diabetes, Type 1, Maternal Grandmother, onset at age 40, still living Heart Disease, Coronary Artery Disease, Father, onset at age 50, still living Depression, Mother, onset at age 30, still living Hyperlipidemia, Father, onset at age 50, still living Stroke, Maternal Grandmother, onset at age 70, still living Vital Signs: Weight: 192 lbs., standing scale Glucose: 155, last meal over 5 hours ago Part Two: Clinical Judgment Activity After reviewing Ms. Muñez’s chart, identify the relevant data related to the patient situation. Analyze the data, ask yourself these questions: What do you notice? (Recognizing Cues/Assessing) What does it make you think? (Analyzing Cues/Diagnosing) What do you think should be done? (Prioritize Hypotheses & Generate Solutions/Planning) What additional information or orders do you need? (Generate Solutions/Planning) Assignment 2.1: Document the answers to the questions in the Notes section > Nursing Note-Progress Note Part Three: Clinical Judgment Activity You alert the healthcare provider to the results of the finger stick blood glucose. The healthcare provider schedules a glucose tolerance test for the 13-week prenatal appointment, along with the already scheduled Nuchal Translucency. The provider asks you to educate the patient on the glucose tolerance test and the Nuchal Translucency Assignment 3.1: Utilize the Patient Teaching tab to document the patient education regarding the upcoming diagnostic testing. When documenting your patient teaching, include the following: Teaching Topic Learning Objectives – make them “SMART” Learner(s) Readiness to Learn Teaching Methods Evaluation Continued Needs Additional Notes – if applicable Debriefing Questions: Upon completing the debrief questions submit them in Canvas How did you feel while completing this assignment? What went well during this activity? What did you find challenging? What health concerns is Ms. Muñez at risk for during her pregnancy? When providing teaching to Ms. Muñez, what was the priority information needed to be provided during the visit?
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