OB Care Plan

Student: Samantha Wiederkehr Date: June 8, 2020

Course: 432CC Instructor: Professor Gayongala

Clincial Site: Grand Canyon Hospital Client Identifier: D.G. Age: 30

Reason for Admission: Scbeduled c-section; pre term birth

Medical Diagnoses: (Include Pathophysiology and Risk Factors): Clinical Manifestation(s):

Preeclampsia begins early in a womans pregnancy and is caused by the
spiral arteries not thinning completely leading to decreased oxygen to the
placenta as well as placental ischemia. Some factors that may put a
woman at higher risk include existing hypertension, gestational diabetes
mellitus, or family history (Perry, Hockenberry, & Olshansky, 2018).
Preterm delivery
Type 2 diabetes
D.G. presents with high blood pressure, high liver enzymes, and
increased protein in her urine.
Preeclampsia can cause a person to have blurred vision or diplopia,
decreased liver function, albumin in the urine, hypertension, and
headaches (Perry, Hockenberry, & Olshansky, 2018).

Assessment Data
Subjective Data: D.G. complains of pain level of 9/10 at inicion site, but other than that she states she is doing good and has no other
complaints.
Vitals: Labs: Diagnostics:
Prior to C-section RBC: (5-6.25) 3.37 (LOW) Ultrasound (06/08/20): breech; LSP
T: 36.9 °C Hgb: (>11) 9.8 (LOW) NST (06/08/20): reactive

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BP: 159/89 HCT: (>33%) 29% (LOW) FHR monitoring (06/08/20): 145bpm; minimal variabilty;
category II
C 64 - Low RBC, Hgb, and HCT may be due to
RR: 16 excess blood loss during c-section, or
anemia caused by pregnancy itself.
O2 Sat: 100% @ RA
Uric Acid: (less than non pregnant: 2.7-7.3)
After c-section 6mg/dL (HIGH)
T: 37.2 °C
- Increased uric acid is most likely due to
BP: 138/85 patient’s preeclampsia.
HR: 95 ALT: (3-21) 85 (HIGH)
RR: 20 - Increased liver enzymes are a result of a
O2 Sat: 99% @ RA decreased in liver function caused by
preeclampsia.
AST: (4-20) 80 (HIGH)
- Increased liver enzymes are a result of a
decreased in liver function caused by
preeclampsia.
Urine protein to Creatinine Ratio: (300) 600
(HIGH)
- Increased urine albumin may be result of
decreased kidney filtration caused by
preeclampsia.

Assessment: Orders:
Neuro: I&O x4 FULL CODE
Cardiovascular: regular rate and rhythm; radial and pedal pulses are NPO until bowel sounds return, then return to a diabetic diet
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2+ bilaterally; capillary refill less than 2 seconds bilaterally Vitals q4h
Respiratory: respirations are unlabored; clear lung sounds upn Monitor I&O
auscultation in all lobes bilaterally
Wound care
GI: bowel sounds not present (too soon after c-section); abdomen is
Ambulate 2-4 times a day as tolerated
non-tender upon palpation (excluding incision site); last BM occurred
before c-section Continuos lactated ringers 125ml/hr
GU: foley catheter in place; voids without difficulty; 1000mL clear, Education:
yellow urine output via foley
- Screening for STIs and UTIs
Delivery/post partum: delivered @ 1200; cesarean; male; 5.2lbs; - Nutrition
NICU - Nonpharmalogical pain management
EBL: 680mL - PPB/PPD and when to contactact HCP

Anesthesia: spinal
Apgar: 6
BUBBLE HE assessment:
Breast: Breasts are full, nipples are intact with no cracking or bleeding
noted, slightly tender
Uterus: firm, midline, palpated slightly above umbilicus
Bowel: Bowel sounds are noted in all 4 quadrants, patients last BM was
before c-section, but patient is passing gas regularly
Bladder: Bladder is empty, foley catheter in place, voiding regularly
and without difficulty
Lochia: lochia rubra noted, no foul odor, no hemrroids noted
Episiotomy/laceration: N/A

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C-section: low transverse incision, glued/well approximated, open to
air, no signs of infection
Homans sign: negative
Emotions: Slightly anxious due to baby being in NICU, overall
exhibiting high hopes, mentally stable, good support system

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 Medications
ALLERGIES: NKDA

Name Dose Route Frequency Indication/Therapeuti Adverse Effects & Nursing

c Effect Side Effects Considerations

Metformin 1000mg PO BID Manages type 2 diabetes by May cause diarrhea, bloating, Monitor patients blood
decreasing glucose nausea/vomiting, hypoglycemia, glucose throguhout therapy,
production and absorption to lactic acidosis, and decreased and be aware that this
maintaining blood glucose Vitamin B12 levels (Vallerand, medicine may cause false-
(Vallerand, Sanoski, & Sanoski, & Deglin, 2017). positive urine keytones
Deglin, 2017). results. Assess renal function
before initiating and
throughout therapy
(Vallerand, Sanoski, &
Deglin, 2017).
Labetalol 20mg IV x1 Manages hypertension by May cause fatigue, weakness, Monitor BP snd pulse
blocking beta receptors in depression, insomnia, arrhythmias, regularly, assess patient for
rder to decreased blood bradycardia, pulmonary edema, orthostatic hypotension
pressure (Vallerand, Sanoski, orthostatic hypotension, constipation, before getting up from bed,
& Deglin, 2017). diarrhea, itching, and parethesia make sure patient is supine
(Vallerand, Sanoski, & Deglin, for 3 hours after IV
2017). administration, and monitor
I&Os (Vallerand, Sanoski, &
Deglin, 2017).
Lovenox 40mg SC Daily Prevents VTE, DVT, and PE May cause dizziness, constipation, Assess for signs and
(enoxaparin) by increasing the effect of increased liver enzymes, urinary symptoms of bleeding or
antithrombin causing a retention, bleeding, anemia, hemorrhage, monitor for
thrombus not to form ecchymosis, arythema at injection hypersensitivity, monitor for
(Vallerand, Sanoski, & site, and fever (Vallerand, Sanoski, & signs and symptoms of
Deglin, 2017). Deglin, 2017). neurologic impairment
(patients with epidural
catheters), monitor CBC,
platelets, and liver enzymes
(Vallerand, Sanoski, &
Deglin, 2017).

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Lactated 1000ml IV 125ml/hr Used for hydration and
Ringers maintenance of fluid and
electrolytes by replacing
fluids when deficient in order
to maintain homeostasis
(Vallerand, Sanoski, &
Deglin, 2017).
Percocet 5/325mg PO Q4H PRN for Used for short-term pain
pain management by binding to
opiod receptors and altering
the perception of pain
(Vallerand, Sanoski, &
Deglin, 2017).
Ketorolac 30mg IV Q6H Management of pain for
short-term periods by
inhibiting prostoglandin
synthesis and decreasing pain
sensation (Vallerand,
Sanoski, & Deglin, 2017).
Nursing Diagnoses and Plan of Care
Goal Expected Outcome Intervention(s)
Client or family focused. Measurable, time-specific, Nursing or interprofessional
reasonable, and attainable. interventions.
Priority Nursing Diagnosis (including rationale for choosing this as the priority diagnosis):
Risk for infection during the postpartum period related to c-section delivery as evidenced by open to air wound with a pain level of 9/10 at
incision. – This was chosen as the priority diagnosis because maternal infection can lead to further complications and delayed recovery time.
May cause HF, pulmonary edema,
hypernatremia, hypervolemia,
hypokalemia, extravasation and
irritation, irritation at IV site
(Vallerand, Sanoski, & Deglin,
2017).
May cause aitation, anxiety, dyspnea,
increased liver enzymes, urinary
retention, blurred vision, insomnia,
and nausea/vomiting (Vallerand,
Sanoski, & Deglin, 2017).
May cause stoke, drowsiness,
myocardial infarction, pallor, GI
bleeding, stevens-johnson syndrome,
toxic epidermal necrolysis, prolonged
bleeding time, and anaphylaxis
(Vallerand, Sanoski, & Deglin,
2017).
Rationale
Provide reason why intervention
is indicated/therapeutic.
Provide references.
Assess fluid balance during
therapy, assess patient for
hyponatremia/hypernatremia,
and monitor serum
electrolytes (Vallerand,
Sanoski, & Deglin, 2017).
Assess pain before and after
administration. Manage
vitals, especially BP, HR,
and RR and monitor for
respiratory depression
(Vallerand, Sanoski, &
Deglin, 2017).
Assess patient for rash
during treatment and
discontinue if seen with
fever, assess pain before and
after administration, evauate
AST and ALT levels, and
assess for bleeding during
therapy (Vallerand, Sanoski,
& Deglin, 2017).
Evaluation
Was goal met? Revise the
plan of care according the
client’s response to current
plan of care.
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Patient’s incision site will
remain free from infection.
D.G will have decreased
pain and show no signs or
symptoms of infection by
the end of shift.
1. Nurse will wash hands
and wear gloves when
coming into contact with
incision.
2. Patient will consume a
diet high in protein and iron.
3. Patient will demonstrate
proper personal hygiene
techniques.
1. Aseptic technique
reduces the risk for
infection by keeping the
incision as sterile as
possible.
2. Diets high in protien,
iron, and vitamin C
promote wound healing.
3. Proper personal hygiene
reduces the risk for
infection and promotes
healing.
D.G. reported pain of
4/10 and showed no
signs or symptoms of
infection by the end of
shift by using aseptic
technique, proper diet,
and proper personal
hygiene.

(Phelps, Ralph, & Taylor, (Phelps, Ralph, & Taylor,

2017). 2017).

Secondary Nursing Diagnosis:

Anxiety related to situational crisis as evidenced by newborn being taken straight to NICU after birth.

Patient will have reduced
anxiety and feelings of
guilt.
D.G. will show fewer
signs of anxiety by the end
of shift.
1. Share information with
patient about newborns
status.
2. Encourage the patient to
use support system.
3. Involve the patient in
decision making about
own and neonate’s care.
1. Sharing this information D.G. showed fewer signs
will help reduce patient of anxiety by the end of
anxiety by providing shift by being reassured of
reassurance. the neonate’s condition,
2. Including the patients having a support system to
support system will allow lean on, and being able to
her to be comforted an make decisions.
cope more effectively.
3. Being involved in
decision making will
provide a sense of control
for the patient.

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 (Phelps, Ralph, & Taylor,
2017). (Phelps, Ralph, & Taylor,
2017).
Definition of Client-Centered Care: Care that is unique to the age/developmental stage, gender, race, ethnicity, socio-economic
status, cultural and spiritual preferences of the individual and focused on providing safe, evidence based care for the achievement of
quality client outcomes.”

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 References

Perry, S., Hockenberry, M., & Olshansky, E. (2018). Maternal child nursing care, sixth edition. St. Louis, MO: Elsevier.

Phelps, L., Ralph, S., & Taylor, C. (2017). Sparks & Taylors nursing diagnosis reference manual (10th ed.). Philadelphia, PA: Wolters

Kluwer.

Vallerand, A., Sanoski, C., & Deglin, J. (2017). Davis’s drug guide for nurses (15th ed.). Philadelphia, PA: F.A. Davis.