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ASSESSMENT/NURSING CARE PLAN RUBRIC

Student Name: Date: Shalama Day 3/21/2012

Each item listed below is worth 1 point (10 possible points) (< 8 points resubmit) Other Documentation Self-Evaluation Instructor Evaluation Rubric Included 1 Shift Report Completed Assessment Complete Patient Data Complete Labs Complete Medication Information Problems Highlighted Appropriate Medical Terminology Nursing Care Plan Appropriate NANDA Evidence Based Quality of Work, Spelling, Grammar 1 1 0.5 1 1 1 1 1 0.5, always been weak with spelling. Spell check does not recognize all of the medical terms Total: 9

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LABOR & BIRTH/NURSING CARE PLAN


Fill out completely. As you fill in the document the table cell will wrap the text that you enter and the table will expand to contain your complete answer. Highlight with yellow any problems or needs. Student Name: Date of Assessment: Shalama Day 3/21/2012 PTs Initials: Co RNs Initials: G1 A0 L0 P0 MG DL

Pregnancy Information: Age 25 EDC Wks. 3/26/2012 gest.39/2 G1 T0 P0

PRE pregnancy General Health (include gynecological history and past medical and surgical history): History of migraines, asthma, and no past surgical history. Past Pregnancies (weight gain, complications, newborn wt., etc.): N/A Psychosocial History (family composition, financial status, employment, cultural issues, etc.): Married for 3 years to husband Mark. Worked as nanny fro the past year. Attends church and has close ties to friends in the church. Mother deceased, father and siblings all live out of state. THIS Pregnancy: Type of Prenatal Care: Care of MD in local office in the town of Clinton, MI. Was admitted into St. Joes for migraines in January 2012. Prenatal Education: Did not take any prenatal classes. Books and Nanning where her source of education. Nutrition And Weight Gain: Pt. states that her diet was good through out the pregnancy. Weight gain of 35 lbs. Substance Use (tobacco, alcohol, drugs, etc.): Denies tobacco, alcohol and drugs use. Medications Taken During Pregnancy: Vicodin, Tylenol 3 for migraines. Prenatal vitamin. Calculate : Hours : 24 STAGE ONE LABOR Minutes (length for your patient) 24 hour and : 45 45 minutes

*Define LATENT PHASE: (Include average length of time for a primipara and a multipara.) 0-3cm cervical dilation, 0-40% effacement. Nullipara/primipara may last up to 9 hours, multipara, last up to 5-6 hours. Contractions last 30-45 seconds and are every 5-10 minutes, intensity mild to palpation. Describe your patients latent phase. The records indicate that the patient spent this phase trying to control the pain and stay comfortable. Nursing notes indicate that she was anxious and concerned about the discomfort of the birthing process. Your Patients Status on Admit: Admitted to L/D on 3/19/2012 for induction

due to IUGR. Onset of AM/PM induction at 1930 labor:Inducti on 3/19/2012 on Station: -2

Dilation: Cervadil given at 21:15 on 3/19. No progression started Pitocin at 09:15 on 3/20. 1-2 dilation Effacement: 70%

*Define ACTIVE PHASE: (Include average length of time for a primipara and a multipara.) 4-7cm cervical dilation, effacement 40-80%. Primipara, lasts up to 6 hours, mulitpara, last up to 4 hours. Contractions last 45-50 seconds and are every 2-5 minutes, intensity moderate to palpation. Describe your laboring woman. What coping skills was she using? Not observed What was your, the nurses, and physicians assessment of your client? Not observed, records of nursing notes stated that labor was lagging Amniotic Fluid: light meconium T: time of rupture: 20:10 No A: amount not observed C: color light meconium O: odor not observed

Antibiotic used for B strep or Yes temp:

Significance: Use of antibiotics for a mother that tested positive for GBS are to protect the newborn against colonization of GBS bacterium, which would cause overwhelming neonatal sepsis. For an increased temperature may be a side effect of chorioamnionitis. Antibiotics are given to decrease the rick of infection. Maternal vital sign ranges? T: 98.8-101.3 HR: 93-129, RR 16-18, B/P 91/54-129/74

FHT ranges? 123-190

Duration, interval, and strength of contractions? Not observed for active phase Pain control: YES IVP: Morphine 5 mg at 05:30 on 3/20 Epidural: yes, Fentenal Citrate with Bupivcanis started at 12:50 on 3/20 10ml/hour in 250ml *Define TRANSITION: (Include average length of time for a primipara and a multipara.) 8-10cm cervical dilation, 80-100% effacement. Primipara, last up to 1 hour, multipara, last up to 30 minutes. Contractions last 60-90 seconds and are every 1-2 minutes, intensity is strong by palpation What symptoms and behaviors did you observe? Not observed How was your patient assisted through this phase of labor? Pt. was assisted by midnight nurse and husband *What interventions were done during Stage One of Labor for comfort, safety, nursing care, and to enhance her labor progress? Include medical and nursing procedures (AROM, EFM, IV, etc.) carried out and RATIONALE for each. None: N/A

Nursing and Medical Procedures Cervidil IV- Lactated ringer

AROM/Amniotomy Oxytocin/Pitocin Drip Who or what interfered with your laboring womans comfort or confidence? Was any of this avoidable? What else could have been done or said to support her? This first time mother did not have much support, other than her husband. She was diagnosed with IUGR, which lead her to be induced. The induction lead to one intervention and then to another. Stage 1 of labor was such a long process for her that she could not take the pain, which lead to more interventions of pain management. This all may have been avoided if there was another ultrasound done to rule out IUGR. The mother and father could have had someone else there for support, laboring is an exhaustive process and it may have been helpful to have someone like a doula to help the family through it. What information or support was provided for her labor partner? Not much, by the time my nurse and I came into the room the husband was exhausted. We where able to give him a break to eat, but that left the mother alone and she was not the happiest about that. SECOND STAGE LABOR *Define SECOND STAGE: (Include average length of time for a primipara and a multipara.) From complete dilation to birth of the newborn; lasts up to an hour for primipara and 30 minutes for multipara. Pelvic phase is the period of fetal descent and Perineal phase is the period of active labor. Strong urge to push during the later perineal phase. Completely Calculate: Hours: Minutes: (length for your patient) dilated at: 2 16 min. 06:25 hours How did your patient move the fetus through the birth canal? Describe her position, breathing, etc. The pt. was in a semi-fowlers position, with her legs bent, and held by her and husband. What assistive interventions were carried out by her labor partner, nurse, nursing student, and doctor or midwife? A trochanter roll was placed under her pelvis, and a towel bar was placed over the bed with a towel pull. Legs where extended between contractions Delivery time of newborn: 09:09 Describe her and her familys reaction at the time of birth. Husband stayed with the mother and mother was very tired. Once the baby cleaned up and ready to go to the NICU, they where able to see her before she went down. Both mother and father kissed the baby, with tears of joy.

Rationale Induction/cervical ripening Fluid and Electrolyte replacement Induction/Accelerate labor

THIRD STAGE LABOR *Define THIRD STAGE: (Include scheduled or emergent C/S.) Separation and delivery of the placenta. The placenta will detach and be expelled from the vaginal opening. Placenta Calculate Length in minutes (for your EBL (estimated blood loss) 500ml for vaginal birth and 1000ml for a cDelivered at: hours: patient) 3 section 09:12 minutes 400 ml *Normal number of cord *Number of cord vessels *Significance of these vessels: 3 observed: findings: Evidence of only one single umbilical artery is association with renal and gastrointestinal anomalies Medications utilized and RATIONALE (for C/S also): Nursing and Medical Procedures Continued to run Pitocin Rationale Help contract the uterus, decreasing the risk for a hemorrhage Messaged the uterus Contract the uterus Monitor and assist with repair of the Must remain with the pt. to provide laceration support FOURTH STAGE LABOR *Define FOURTH STAGE: Beings after the placenta is expelled and lasts up to 4 hours after birth, during which time recovery takes place. Include physical conditions, vital signs, and 8 point check: B: Not able to start breast feeding at this time, baby directly to the NICU U: Checked every 15 min., messaged and position assessed. B: Foley straight cath., 350 ml of urine. B: Bowel sound present L: rubra, moderate amount E: stage 3 lacerations, repaired by the attending resident. Area was bruised. E: Slight edema in legs, feeling returning slowing after the epidural was D/C. E: Mother was exhausted from the long labor. She was also upset that the baby had to go to the NICU. Describe ALL nursing interventions done during this stage (be objective). Provided support and information about the repair of the laceration. Applied an ice pack to the perineum, to help reduce the swelling and promote comfort. Monitored vital signs and fundal and lochia status every 15 min., documented. Offered warm blankets. Provided urine relief with a foley catheter. Educated the mother about uterine firmness and how to promote the return of the uterine to pregnancy shape. What was done to enhance the attachment process? Baby was brought back to the family after two hours in the NICU, promoted holding and bonding with her. Present OBJECTIVE evidence that the mother and father were (or were not) attaching to their newborn.

Cesarean Birth Questions (use ONLY for cesarean births) What was the reason for the cesarean birth? What was done to prepare this mother for her surgery? How did the mother and her support person(s) cope with the decision to have a surgical

birth? What anesthetic was used? Describe the operation: Start OR Time Time of Birth BABY Apgars: 1 9 End OR Time Time of Placenta 5 9 10 Not obtained

What did the nurse do for the neonate right after birth? Neonate was taken care of by the NICU team What normal neonatal characteristics did you observe with the physical assessment? Were there any obvious defects? She was normal at time of birth, there where no obvious defects. Instructions: Referring to the highlighted problems/needs, list NANDAS related to labor and birth. NANDAS (List 5) Health Seeking Behaviors: Labor R/T desire for a safe labor and vaginal birth of a healthy newborn. Anxiety r/t infection Risk for Injury: Maternal and Fetal R/T Infection: Maternal/Fetal r/t invasive procedures Risk for Deficient Fluid Volume r/t decrease intake and increased losses Choose one NANDA and create one nursing care plan.

LABS
Prenatal Results Admission Results Normal Finding s 10-14 g/dl Explanation (from text)

Hemoglobin Hemalocrit RBC

L 9.8 gm/dl L 29.9 % L 3.54

3242%

WBC Platelets

9.1 thou/mcl 232 thou/mcl

500015000 / mm3

To determine if the pt. is anemic To determine if the pt. is anemic To determine if the pt. is anemic To determine if there is an infection present. Will increase due to immune stress response necessary for coagulation Rh- mother, birthing a Rh+ baby could lead to problems with future pregnancies Antibody screen to determine whether the mother has developed isoimmunity to the Rh antigen. This test detects unexpected antibodies in a womans serum that could be harmful to the fetus. Determine if you are protected from Rubella. Checks for infection with the Hepatitis B virus, which can be passed to an unborn child. If positive the mother can be given zidovudine to reduce perinatal transmission. Pregnant women with STIs can transmit the infection to their children, resulting in significant morbidity and mortality checks for abnormal cervical cells GBS may cause an overwhelming neonatal sepsis This test measures the levels of AFP, HCG, estriol, and inhibin A in your blood. These levels are then used to calculate the risk of

Blood Typing

O+

COOMBS Rubella Titer

Neg. Immune

Hep B

Neg.

HIV Testing

Neg.

Neg.

STI Screening (RPR) Cervical Smears (PAP) Group Beta Strep (GBS) Other 15-18 weeks Quad Screen

Neg. Not obtained Neg. Not obtained

chromosomal or neural tube abnormalities in your baby. Check the fetus of a pregnant woman for brain or spinal Not problems and for Down obtained syndrome. 13-20 weeks AFP This test measures blood Not sugar levels to check for risks 28 weeks 1 hr glucose obtained for gestational diabetes. Tolerance Test Ultra Sound: Diagnosed Assess the baby's well-being with IGUR, and position, diagnose sex of the multiple gestations (twins, baby is a triplets, etc.) and estimate a girl delivery date Amniocentesis: Genetic screening, recommended for high risk patients. N/A Non-Stress Test: a screening test used in pregnancy. A cardiograph is used to monitor the fetal heart rate. N/A * Explain why test was ordered. Correlate abnormal findings to clients condition. List all other applicable labs drawn on pt during this admission. Current Medications Drug Cervidil Action/Indication Directly softens and dilates the cervix/ cervical ripening and inducing labor Nsg Implications Provide emotional support Administer pain medication as needed Frequently assess degree of effacement and dilation Monitor uterine contractions for frequency, duration, and strength Assess maternal vital signs and FHR pattern frequently Monitor for adverse effects such as N/V, headaches and diarrhea Administer as an IV infusion via pump, increasing dose based on protocol until adequate labor progress is achieved Assess baseline vitals Monitor uterine contractions for frequency, duration, and strength Maintain careful I & O, be alert for water intoxication Keep pt. informed of labor

Oxytocin/pitocin

Acts on uterine myofibrils to contract/augmentation of labor and artificial induction

progress Monitor for possible adverse side effects such as hyperstimulation of the uterus.

Epidural, Fentanyl Citrate and Bupivcanin 2 mcg/ml

Local anesthetic with opioid/ loss of sensation and pain

Monitor fetus for distress Monitor for hypotension, fever, pruritus and respiratory distress Assess fetus for respiratory distress secondary to maternal hypotension

Tylenol 250mg/tab x 2 tabs Zofran 4mg

Nonnarcotic analgesic, to relieve mild to moderate pain Antiemetic/ to prevent nausea and vomiting

N/V Anemia May cause flushing of the skin, constipation, and CNS adverse reactions such as anxiety, headaches, hypotension and agitation. Monitor for chills, fatigue, headache Assess for urine retention

Ampillen 2 gm

Antibiotic/treat bacterial infections

Gentamicin 100mg/50ml

Antibiotic/to treat bacterial infections

Monitor vitals Assess for confusion, headache, and neurotoxicity Monitor for respiratory depression

Motrin 500mg/tab

Analgesic, anti-inflammatory/ relieve mild to moderate pain

Monitor I&O Assess for GI upset Assess skin for sigh of a rash Take with food

Morphine 5mg/IVP

Analgesic/provide pain relief for moderate to severe pain

Monitor respiratory status Monitor vitals Have pt. change positions slowly to minimize the effects of orthostatic

hypotension Monitor pt. for excessive or persistent sedation Have oxygen on hand if needed

NURSING 132 CARE PLAN EXPLANATION


Assessed Data Nursing Diagnosis Expected Outcome Nursing Interventions Dx Tx Ed Rationale Scientific Resource Evaluation/SOAP Date Time Signature

S: Pt. States that she is very warm and would like a cool wash cloth on her face. O: Pt. vitals range from Temp. 98.8101.3 HR: 93-129 RR: 16-18 B/P: 91/54129/74 Skin warm and flush. Fetus and mother both tachycardic FHR range 123-190 Given Ampillen and Gentamicin during labor Lactated ringer running 125ml/hr EpiduralFentanyl/bu pivcanin

Hyperthermi a R/T Physiologic response to infectious process. AEB Increased temp. Suspected

GOAL Marys temperature will be <102F until she is passed stage 3 of labor and will return to normal range between 97.6-99.6F after birth AEB EXPECTED OUTCOMES Temperatures within normal range Heart rate within normal range Pt. is well hydrated, moist mucous membranes, good turgor.

Dx Ongoing assessment Assess temperature, BP, pulse, and respiration every 15 min. Assess for dehydration, I&O Assess fetal heart tones, q 15min. Assess contractions q 15 min.

chorioamnio nitis

Tx Performing skills Provide fluids either by mouth or IV, lactated ringer Use prophylactic antibiotics Encourage and provide for rest

Ed Teach the patient Teach pt. to recognize dehydration and to increase fluids early Teach the pt. and family about hand washing before and after caring for the pt. Teach pt. to avoid

Provides informatio n about tempature changes, vital sign response: with increased temp., HR increased, respiration increased. BP may decrease as a result of hypovole mia Assessment provide informatio n about hydration staus Maternal fever and dehydratio n cause fetal tachycardi a. Hypovolemia may compromi se placental flow and lead to fetal distress Maternal dehydratio n is implicated in uterine contractio ns. Maintains hydration as fluid is lost from hyperther

Date___March 28th, 2012___Time___21:1 9___ S: Pt. states that she feels much better when she can rest with a cold towel on her head.

O: Gave Ampillen and Gentomicin prophylactic. V/S within normal ranges Temp. 98.8F during stage 4 of labor. HR 93, RR 18, and BP 129/74 Provided cool cloth her head, and soothed pt. during recovery Assess FHR, contractions every 15 min. during stage 2 of labor. Ran 1000ml bag of lactated ringer at 125ml/hr. X 4 Straight foley cath. X 3 Encouraged rest between contractions. Assisted pt. with resting legs between contractions. Encouraged PO fluid intake, taught pt. the importance of staying hydrated. Showed husband proper hand washing.

A: Goal met, pt. fever gone by the time she was transferred to M/B unit.

contact with people with infection

mia Pregnant women have a increased need for fluids Protects the pt. from the spread of infection P: Continue proper hand washing technique, monitor mother for 24 hour after birth. Provide education about S/S of infection went at home.

SHIFT REPORT/Highlight risks/needs in yellow


Roo L/D 6 m: Support Donna L. Nurse: Mothers Name MG Initials: Gravi 1 Par Todays Date: March 21, 2012 Tasks : 700

Baby:

Boy

Girl

da G 1 T 0 P 0

a 800 A 0 L0 Date of Birth: Time of Birth: APGAR Score: Breast x March 21, 2012

Allergies/Sensitiviti es: NKA Due 3/26/2012 Date: Vaginal Vacuum

Gestational Age: Forceps

39-2

09:09

900

9/9 1000 Bottle x

EBL: 400 ml CSection: Reason:

Time of Last Feeding: Blood Type: Rhogram Candidate: GBS: O+ Neg. Positi ve Positi ve Immu ne Lactation x Negativ e Negativ e Bathed: No

Given a bottle in the NICU

1100

1200 Hepatitis B Vaccine: x Circed: Newborn Screen: 1400 Rubella: Referral s: Not Immune Hearing Screen: Birth Weight: Present Weight: Weight Loss: % Weight Loss: Void Medication Cervadil, Morphine, Zafran, Tylenol, s: Fentanyl/Bupivcanin epidural Ampillen and Gentomicen for chorioamnionitis Lactated Ringer Pitocin Motrin Stool 1700 Medications : Vit. K Eythromycin Ophthalmic Ointmemt Ampillen and Gentomicin 6lbs 14oz, or 3118 gm 1500 1300

Hepatitis B:

1600

1800

1900 Risks/Needs/NAN DA: Hyperthermia r/t physiologic response to infection Anxiety r/t the effects of prenatal infection on fetus Risks/Needs/NAND A: At risk for infection

2000

2100

2200

2300