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PATIENT/CLIENT DATA - CLINICAL DECISION-MAKING WORKSHEET

NUR 4141 Women and Newborn Health Nursing


Student Name:

Clinical Week #

Focus of Care Plan:

Date(s) of Care: 2/6/16

Labor/Delivery

Patient Demographics, Health History and Admission History


Patie
nt
initial
s:

Se
x:

Ag
e:

Roo
m:

Admitti
ng date:

Reason for admission:


Pregnancy; Induction of Labor

29

4425

2/4/16;
18:40

K.R
Attending physician/treatment
Consultants seen during this hospitalization:
team:
Anesthesiologist
Jamie S. Januszyk, MD
Present diagnosis:
ER management:
Caesarean section due to prolonged
None
labor; Lack of progressive cervical
dilation
Allergies:
Code status:
Isolation status:
Amoxicillin
Full Code
None
Admission height:
Admission weight:
Arm band status:
157.48 cm.
89 kg
Red-Allergies
Communication needs:
Pt. speaks English
Past medical/surgical history:
None
Significant events during this hospitalization:
Caesarean Section due to prolonged labor; Lack of progressive cervical dilation
Tests or treatments impacting clinical days care:
None
Advance directives/ethical considerations: (DPOA, Hospice, DNR, Living Will, etc.)

Rev. 1/16

None
Pregnancy history:
Gravida: 1
Year

2016

Para T (Term): 1

Weeks
gestatio
n
41

Outcome
(SAB, IAB,
NSVD,
C/S)
C/S

P (Preterm): 0

A (Abortions/miscarriages): 0 L (Living children): 0

Sex of Complications to pregnancy, labor/birth, or


infant postpartum
M

Induction of labor; C/S due to lack of


progressive cervical dilation

History of current pregnancy:


LMP: 4/23/15
EDD: 1/30/16
Gestational age: 41 weeks
Total number of prenatal visits: Pt. did not know that exact number of times but did attend all prenatal visits.
Complications or risk factors during current pregnancy: Induction of labor; C/S due to lack of progressive cervical
dilation
Prenatal education: Birthing classes and books on newborn child care.

History of current labor and birth:


Onset of labor: 2/4/16; 20:00; Pitocin administration
Rupture of membranes: 2/5/16; 17:08; Artificial rupture
Color of fluid: Bloody
Delivery date & time: 2/6/16; 07:29
Weeks gestation: 41
Delivery type:
Caesarean Section
Newborn weight: 6 lbs. 14 oz.
Total length of labor: 35 hrs.
Fetal presentation at delivery: Cephalic
Episiotomy and/or laceration: Intact; No laceration or Episiotomy
Estimated blood loss (EBL): 800 ml

Rev. 1/16

Anesthesia type (epidural/local/IV/none): Epidural


Labor complications: Induction of labor; C/S due to lack of progressive cervical dilation
Newborn History:
Gestational age by dates: 40 weeks 6/7 days
Gestational age by exam: 41 weeks
Birth weight: 6 lbs. 14 oz.
Length:
Head circumference:
Chest circumference:
Blood type (if done):
Delivery date & time: 2/6/16; 07:29
Delivery type: Caesarean section
1 minute APGAR score: 9
5 minute APGAR score: 9
Type of anesthesia for delivery: Epidural
Method of Feeding: Breast fed

Health Assessments
Vital Signs:

Rev. 1/16

Pain Assessments and Interventions:

Time

_7:00__
a.m.
T
97.8 F; Oral
P
108;
Automatic
R
18;
Observed
B/P
110/62;
Automatic
Pulse Ox 97%
Pain
7
Score

__12:05_
p.m.
99.2 F; Oral
108;
Automatic
16;Observe
d
123/82;
Automatic
97 %
0

Respiratory Assessment and Interventions:


Respirations 18/min, relaxed and even. Breath
sounds clear and equal bilaterally. Chest
expansion symmetric. Lung sounds clear, no
signs of wheezing or stridor.
Interventions:
-Monitor respirations and SpO2
-Monitor for any respiratory alterations due to
epidural anesthesia

Pt. stated pain was 7/10 on a numerical scale. Pt. states


pain is due to contractions.
Pt. administration of Pitocin and Cervidil, 2/4/16; 20:00,
for induction of labor. Pt. scheduled for a C/S on the
morning of 2/6/16; 07:00, due to lack of progressive
cervical dilation.
Intervention:
-Administration of anesthesia, combined spinal epidural,
prior to C/S by anesthesiologist; 2/6/16; 07:10 am.
-Monitor baseline levels for pulse, BP, respirations, and
relaxed muscle tone or body posture, adjust
medications appropriately
-Pain assessment and management
-Pharmacological/nonpharmacological pain relief
strategies (Controlled breathing techniques)
-Evaluate patients response to pain and medication or
therapeutic treatment
Neurosensory Assessments and Interventions:
Pt. alert and oriented 4x and maintained good eye
contact and responded appropriately to questions, prior
to administration of epidural anesthesia. Pupils equal
and round. No presence of tremors, numbness or
paralysis.
Pt. had administration of anesthesia, combined spinal
epidural, prior to C/S by anesthesiologist; 2/6/16; 07:10
am.
Interventions:
-Assess neurological function
-Assess level of consciousness; A & O
-Monitor/Assess fall risk

Cardiovascular Assessments and Interventions:


HR taken electronically found to be 108
beats/min; Sinus tachycardia with regular rhythm.

Rev. 1/16

Musculoskeletal Assessments and Interventions:


Signs of weakness in lower extremities related to
administration of epidural anesthesia.

BP = 110/62. 1+ lower edema noted. 800 ml


estimated blood loss during C/S.
Sinus tachycardia related to induction of labor,
contractions and pain.
Interventions:
-Assess vitals; BP and Pulse
-Check lower extremities for edema; chart any
changes (worsening or improvement)
Renal Assessments and Interventions:
Pt. had a urinary catheterization,
indwelling/continuous, 16 French placed 2/5/16;
15:49. Urine was clear.
In/Out
Total In
Total
Out
Balanc
e

2/5
2733.6
3000

2/6
1000.5

-266.4

1000.5

Interventions:
-Monitor input/output

Gastrointestinal Assessment and Intervention:


Pt. reports no nausea or vomiting.

Interventions:
-Monitor/Assess fall risk
-Educate pt. on fall risk related to epidural anesthesia
-Monitor to ensure pt. safety.
-Placed side rail up 2x, bed at lowest position and call
light within reach

Skin and Integument Assessments and Interventions:


Pt. had surgical incision made on the lower, transverse
abdomen. Internal sutures and surgical glue used for
closure; abdominal surgery. Open to air. Skin warm, dry
and smooth. Skin color consistent with ethnicity, no
pallor or cyanosis noted. Nail beds pink. 1+ edema
noted in lower extremities.
Interventions:
-Assess for risk of pressure ulcers due to post-op
bedrest
-Smooth out linen in order to prevent irritation and
pressure points
-Check lower extremities for edema; chart any changes
(worsening or improvement)
-Monitor abdominal incision for any signs of infection or
dehiscence
Endocrine Assessment and Interventions:
Pt. has no history of diabetes, thyroid or lipidemic
problems.

Pt. was NPO prior to C/S. Pt. advanced to clear


liquid diet, post-op; 2/6/16, 08:16.
Interventions:
-Assess bowel sounds
-Ask about bowel movement history and
frequency

Rev. 1/16

Interventions:
-Monitor glucose

-Assess for nausea and vomiting

Vascular Access Assessment and Interventions:


18 gauge in rt. wrist; 2/4/16, 19:40.
Interventions:
-Monitor dressing
-Change IV tubing every 72 hrs. to prevent
contamination
-Observe for potential complications
-Keep IV site clean
-Practice strict asepsis

Post-operative/Post-procedural Assessment and


Intervention:
Pt. had surgical incision made on the lower, transverse
abdomen. Internal sutures and surgical glue used for
closure; abdominal surgery. Open to air.
Interventions:
-ABCDE assessment (Airway, Breathing, Circulation,
Disability and Exposure)
-Prevent risk of infection; Teach proper hand washing
-Pain management
-Assess for fall risk
-Help maintain pt. safety
-Monitor vitals every 15 mins. first hr., every 30 mins.
second hr. and hourly third and fourth hr. Then Q4-Q8 as
prescribed by physician.

Reproductive:
Pt. stated no reproductive history of problems
(Abortions or miscarriage).

Safety Assessment and Interventions:


Pt. has I.D bands in place. Bed placed at lowest position
to prevent falls. Call light within reach.

G1P0. Pt. administration of Pitocin and Cervidil,


2/4/16; 20:00, for induction of labor. Pt. scheduled
for a C/S on the morning of 2/6/16; 07:00, due to
lack of progressive cervical dilation. C/S birth of a
baby boy on 2/6/16; 07:29. 800 ml blood loss. No
complications.

Interventions:
-Place bed at lowest position to prevent falls, especially
when pt. is in recovery/post-op; Fall risk due to epidural
anesthesia
-Re-Assess fall risk and adjust plan of care accordingly

Interventions:
-Monitor for signs of hemorrhage
-Assess uterine firmness, location, position and
amount of lochia
-Monitor vitals every 15 mins. first hr., every 30
mins. second hr. and hourly third and fourth hr.
Then Q4-Q8 as prescribed by physician.

Rev. 1/16

Psychosocial Assessment and Interventions:


No history of mental illness. No history of substance abuse. Never a smoker. No alcohol. Pt. is married and
husband has been supportive and at the bedside since arrival to the hospital. Pt. did express anxiety and
fear over caesarean birth procedure.
Interventions:
-Involve family in the care of the pt.
-Provide counseling and moral support, as needed
-Address any questions or concerns promptly
Cultural/Spiritual Assessment and Interventions:
N/A; Pt. did not mention any religious or spiritual preference.
Interventions:
-Provide spiritual counsel (Priest or rabbi, etc.), if applicable
Growth & Development Assessment and Interventions:
According to Erikson, this pt. is in the stage of life where, intimacy vs. isolation, is the focal point. During
this stage, young adults seek mutually satisfying relationships, including friends and marital partners.
Many of them start families. Those who negotiate this stage successfully can experience intimacy on a
deeper level. Those who fail to do so become isolated and distant form others. Eventually, they may
withdraw socially.
This pt. is 29 years old, married and having her first child. She has achieved a level of intimacy with her
husband that has led to the point of conception and now birth of a baby boy. Pt. seems to be excited about
the birth of her child and is secure in her relationship. Pt. has support of her husband who has been at her
bedside since arrival to the hospital. The only concern this pt. has is a bit of anxiety/fear over scheduled
C/S. With the support of family and the staff, we will listen and address these concerns to put pt. at ease.
Intervention:
-Include family in the assessment of the pt.
-Listen to any fears and concerns
-Answer questions and give support

Rev. 1/16

Pertinent Diagnostic Data


Maternal
Diagnostic
Data
Blood type (A, B,
O, AB)
Rh factor (+ or
-)
Antibody screen
(if Rh negative)
Prenatal H&H

Results and
date
2/5/16
O
+
N/A
41; 12.5

Postpartum H&H
Rubella status
GBBS
WBC
RBC
Platelets
Newborn
Diagnostic
Data
Blood type (A, B,
O, AB)

Rev. 1/16

Normal Lab
Values

Immune
Negative
9.11
4.62
266

38-50; 12.116.4
38-50; 12.116.4
4.5-10.5
4-5.4
150-400

Significance within your patient

Rh factor (+ or
-)
Coombs test
Blood glucose
Cord blood
bilirubin
TCB/Serum
bilirubin (please
note whether
value is
transcutaneous
or serum)
Write in any
other NB labs
below:

Pharmacological Intervention
Medication

Pitocin

Dose, Route
and
Frequen
cy
30
units/500
ml, IV

Classificatio
n

Purpose/Mechanis
m of Action

Oxytocic

-Given to this pt.


for induction of
labor
-Stimulates
contraction of
uterus and
lacteal glands in
breast promoting
milk ejection.
Also given for
uterine atony
after delivery

Rev. 1/16

Significant Side
Effects /
Adverse
Reactions
This pt. did not
show any signs
of sign effects or
adverse effects.
*Can cause
hypertension,
uterine
hypertonicity,
water
intoxication,
ergotism, cardiac
arrhythmias

Nursing Implications

-DO NOT use if allergy,


cephalopelvic disproportion or
unfavorable fetal position
-Discontinue if prolonged
uterine contractions occur
and/or if fetal distress is noted
on EFM
-Assess blood pressure and
pulse every 15 minutes

Medication

Dose, Route
and
Frequen
cy

Classificatio
n

Purpose/Mechanis
m of Action

Cervidil
(Dinoprosto
ne)

10 mg,
Vaginal,
Once

Prostaglan -Given to this pt.


din
for induction of
labor
-Works by
causing
softening and
dilation of the
cervix

Ondansetro
n

4 mg, PO,
Q4H

Antiemeti
c

-Given to pt. for


nausea and
vomiting
-Serotonin 5-HT3
receptor
antagonist used
to prevent
nausea and
vomiting

Fentanyl

25 mcg, Inj.
IV push,
Once

Opioid
analgesic

-Given to this pt.


post-op
-used to relieve
pain during labor
(with mild
sedation)

Rev. 1/16

Significant Side
Effects /
Adverse
Reactions

Nursing Implications

This pt. did not


show any signs
of sign effects or
adverse effects.

-DO NOT give if known


hypersensitivity to
prostaglandins, unexplained
vaginal bleeding, multi-para
with 6 or more previous
pregnancies, fetal distress or
previous C/S
-Keep frozen until use
-Patient needs to be in
recumbent position for 2 hours
after insertion

*Can cause
uterine rupture,
fetal/ neonatal
death, glaucoma,
fetal distress,
decrease uterine
integrity.
This pt. did not
show any signs
of sign effects or
adverse effects.
*Can cause
constipation,
dizziness,
headache,
fatigue,
drowsiness,
diarrhea, fever
and urinary
retention.
This pt. did not
show any signs
of sign effects or
adverse effects.
*Can cause
nausea,

-Teach to report diarrhea,


constipation, rash or changes in
respirations or discomfort at
insertion site
-Avoid if pregnant or breast
feeding, children, geriatric
patient or granisetron
hypersensitivity

-DO NOT give to pts. who have


received MAOIs, who have had a
history of substance abuse or
myasthenia gravis.
-Monitor vital signs
-Observe for skeletal and
thoracic muscle rigidity and

Medication

Ketorolac
(Toradol)

Dose, Route
and
Frequen
cy

30 mg, Inj.
IV push,
Q6H

Classificatio
n

NSAID/
Analgesic

Purpose/Mechanis
m of Action

-Given to this pt.


for breakthrough
pain post-op
-Action: related
to prostaglandin
synthesis
inhibition
Effect: Reduces
hormones that
cause
inflammation and
pain in the body.
Uses: Pain relief
during labor

Rev. 1/16

Significant Side
Effects /
Adverse
Reactions
vomiting,
dizziness,
decreased gastric
mobility and
respiratory
depression

Nursing Implications

This pt. did not


show any signs
of sign effects or
adverse effects.

-DO NOT use Toradol if you have


any active or recent bleeding
(including bleeding inside your
body), a head injury, a stomach
ulcer, severe kidney disease, a
bleeding or blood-clotting
disorder, a history of severe
allergic reaction to aspirin or an
NSAID, if you are scheduled to
have surgery, if you are in late
pregnancy, or if you are breastfeeding a baby.
-Inform patient of gastric upset
issues
-Patient must report pain levels
-Monitor vital signs for
indications of effectiveness

*Can cause
anaphylaxis due
to
hypersensitivity,
nausea, GI
bleeding,
sedation,
hypotension or
hypertension,
rash, headache,
and edema

weakness.
-Monitor for respiratory
depression

Current Plan of Care:


Management of pain. Ask patient about any concerns or fears they might have and
address them prior to the scheduled procedure. Make sure all consents are signed.
Make sure all procedures have been explained and understood by the pt. Explain
what is expected of the pt. following the procedure, such as early ambulation and
incentive spirometry to prevent pneumonia. Help minimize the risk of infection postop by teaching proper hand hygiene, prevent DVTs and manage bleeding in order to
minimize/prevent the occurrence of postpartum complications.
Discharge Plan:
If there are no complications with either pt. or neonate, they may be discharged
home, 3 days after the scheduled caesarean birth or 2/9/16. This pt. is married and
will be going home with her husband and newborn.
Teaching Needs:
Talk about safety and fall risks due to opioid use
Teach mother about proper hand washing techniques
Talk about pain management
Education on medication administration
Talk about early ambulation to prevent DVTs post-op and use of incentive
spirometry
Talk about normal signs and symptoms post-op, such as normal lochia color and
quantity; involution contraction/pains
Talk about signs of infection or hemorrhage to be reported to nurse or
physician

12

Normal Physiology Discussion:


During labor, the body goes through different stages in order to deliver the fetus. There are three basic stages of

labor: dilation, expulsion and placental delivery. There are also a myriad of other actions, before and during the process of
labor that the body takes in order to achieve parturition or the forcible expulsion of the fetus from the mothers uterus.
Beginning with contractions or the involuntary smooth muscle flexing of the uterus, the body begins its job of moving the
fetus into position for birth. These contractions begin as minor discomfort and gradually escalate into full discomfort. At this
time, the mother may choose pain relief from epidural injections that numb the lower extremities. Dilation of the uterus is the
opening and widening of the cervix to 10 centimeters. This is when contractions increase and the amniochorionic membrane
inside the uterus ruptures, releasing the amniotic fluid; can also be described as water breaking. The fluid aids not only in the
expulsion of the fetus, but also protects it from infection. If the water break too early, mothers are given antibiotics to protect
the fetus. In the third stage, expulsion; contractions push the baby through the birth canal and out into the world.
After delivery of the fetus, the body changes its focus toward the placenta. The placenta, is first shrunken down by a process
called myometrial retraction, then detaches itself from the uterine wall and with the help of uterine contractions is propelled
downward and out via the uterus.

Pathophysiological Discussion: Induction of labor


Cellular Level/Pathophysiologic mechanism:
Induction of labor is a process where due to post-term dates, lack of contractions and/or other complications, a physician will
administer medications to start labor or stimulate labor. Oxytocin is a hormone that is naturally secreted in the body to help
stimulate contractions but there may be a lack of secretion due to lack of stretching of the cervix and uterus. The pt. will not
go into labor if there is no stimulation from the cervix or uterus for the release of oxytocin. Oxytocin is produced in the
hypothalamus and is stored in the posterior pituitary gland. It is normally released due to stretching of the cervix and uterus
during labor but if there is no release of oxytocin or not enough, Pitocin (oxytocin) administration will stimulate uterine
contractions and can accelerate labor.
Patient Encounter:
This pt. came in for an induction of labor due to fetus being post EDD. The pt. was administered Pitocin and Cervidil, in order
to help stimulate uterine contractions and accelerate the labor process. After about 34 hours of labor, the decision was made
to have a caesarean section due to lack of cervical dilation as the pt. had been 5 cm dilated for about 5 hrs. with no
advancement in fetal decent.

13

Epidemiology:
Its not quite clear as induction of labor has become more of an elective procedure.
Etiology: (Risk factors as to why an induction of labor may occur)

You're approaching two weeks beyond your due date, and labor hasn't started naturally
Your water has broken, but you're not having contractions
There's an infection in your uterus
Your baby has stopped growing at the expected pace
There's not enough amniotic fluid surrounding the baby (oligohydramnios)
Your placenta has begun to deteriorate
The placenta peels away from the inner wall of the uterus before delivery either partially or completely (placental
abruption)
You have a medical condition that might put you or your baby at risk, such as high blood pressure or diabetes

Medical and Surgical management of Alterations:


-Provide relief of symptoms
-Physician to give treatment options: Medication or C/S; depending on pt. diagnosis
Common Complications:
Labor induction carries various risks, including:

Need for a C-section


Premature birth

Low heart rate in mother and/or fetus

Infection

Umbilical cord problems

14

Uterine rupture

Bleeding after delivery

Patient Prognosis:
Pt. had an induction of labor which was successful in starting labor but due to lack of cervical dilation and fetal decent, the pt.
had to have a caesarean section. Pt. had a successful c/s and delivered a healthy baby boy on 2/6/16; 07:29.

15

Nursing Diagnoses
Priority
1

Nursing Diagnosis
Acute Pain

Related to
Induction of Labor

As Evidenced By
Pt. verbalization of pain
7/10 on numerical scale

Anxiety/Fear

Caesarean Birth

Pt. verbalization of
anxiety/fear over
invasive surgery

Risk for Shock

Hemorrhage

Blood loss during


caesarean birth

Risk for Infection

Caesarean Birth and


Surgical incision

Lower abdominal, bikini


line incision

Risk for Maternal


Injury

Falls

Use of narcotic
analgesics/Epidural

Rationale
This would be my top priority for this pt.
This pt. had an induction of labor with
the use of Pitocin. The administration of
Pitocin causes the uterus to contract
and is painful.
This would be my second priority for
this pt. We must address any questions
or concerns about the procedure for the
pt. to help put them at ease.
Although hemorrhage is a big concern,
this pt. did not experience excessive
blood loss. We must continue to monitor
pt. post-op for any signs of hemorrhage.
This pt. may be at risk for infection due
to surgical incision. We must teach
proper handwashing to pt. in order to
avoid any infection of the incision site
post-op.
This pt. is a fall risk due to the use of
analgesics. We must monitor pt. and
ensure pt. safety. We must assess and
re-evaluate fall risk and adjust plan
accordingly.

16

Nursing Management and Intervention


Nursing Diagnosis #1: Acute Pain related to induction of labor as evidenced by pt. verbalization of pain
7/10 on numerical scale
Assessment or data
collection relative to
the nursing
diagnosis
(Provide subjective and
objective assessments)

Pt. stated pain was 7/10 on


a numerical scale. Pt.
states pain is due to
contractions.
Vital Signs:
Time

_7:00__
a.m.
T
97.8 F; Oral
P
108;
Automatic
R
18;
Observed
B/P
110/62;
Automatic
Pulse Ox 97%
Pain
7
Score

Patient Outcome
(objective,
expected or
desired
outcomes, or
evaluation
parameters)
[Remember the
S-M-A-R-T
acronym]
- Patient will maintain
pain level at a 3/10 or
below for the
remainder of the shift
-Patient will have a
controlled level of
pain as evidenced by
the patient verbalizing
pain of 3 or less on a
pain scale of 0-10 by
the end of shift on
2/6/16.

Interventions/Implementation
s and Rationale
(specific nursing actions)

-Anesthesiologist
administered epidural which
will help with pain due to
labor
-Administration of Toradol; 30
mg, Inj. IV push, Q6H for
breakthrough pain post-op

Evaluation
(Include whether
outcome
was met or
unmet)

Outcomes met:
-Pt. verbalized
pain at 0 out of
10 prior to
transfer to postpartum unit

-Monitor vitals every 15 mins.


first hr., every 30 mins.
second hr. and hourly third
and fourth hr. Then Q4-Q8 as
prescribed by physician postop
-Evaluate response to pain
management to make sure
medication is working; adjust
medication accordingly
-Monitor for adverse effects
of medication; respiratory

17

depression
-Implement comfort
measures such as adjusting
pillows
Pharmacological/nonpharmac
ological pain relief strategies
(Controlled breathing
techniques)

18

Assessment or data
collection relative to
the nursing
diagnosis
(Provide subjective and
objective assessments)

Pt. did express anxiety and


fear over caesarean birth
procedure.
Pt. administration of Pitocin
and Cervidil, 2/4/16; 20:00,
for induction of labor. Pt.
scheduled for a C/S on the
morning of 2/6/16; 07:00,
due to lack of progressive
cervical dilation.

Patient Outcome
(objective,
expected or
desired
outcomes, or
evaluation
parameters)
[Remember the
S-M-A-R-T
acronym]
-Pt. will remain
relaxed prior and
during the scheduled
c/s 2/6/16; 07:00.
-Pt. will understand
what to expect during
and after the
procedure; 2/6/16;
07:00.
-Pt. will be relaxed as
evidenced by pt.
verbalize of being
relaxed and
understanding the
outcomes of the
procedure

Interventions/Impleme
ntations and
Rationale
(specific nursing
actions)

-Provide counseling
and moral support, as
needed
-Address any questions
or concerns promptly
to put pt. at ease

Evaluation
(Include whether outcome
was met or unmet)

Outcome Met:
-Pt. stated during
recovery period, I was
worried and everything
went well.

-Pt. stated
understanding
-Make sure all consents procedure and knew
are read, understood
what to expect after the
and signed
procedure
-Call or consult with
physician to make sure
pts. concerns are
appropriately
addressed
-Explained procedure
to pt. in order to put

19

pt. at ease and make


her feel more in
control of the situation
-Implement comfort
measures such as
adjusting pillows
Nursing Diagnosis #2: Anxiety/Fear related to caesarean birth as evidenced by pts verbalization of
anxiety/fear over invasive procedure

References
ATI Nursing Education. (2013). RN pharmacology for nursing. Assessment Technological Institute, LLC.
Gulanick, M., & Myers, J. L. (2011). Nursing care plans. St. Louis: Elsevier Mosby.
Ralph, S. S., & Taylor, C. M. (2011). Nursing diagnosis reference manual. St. Louis: Wolters Kluwer Health| Lippincott Williams &
Wilkins.
Ricci, S.S. (2013). Essentials of maternity, newborn, and womens health nursing (3rd ed.). Philadelphia: Lippincott Williams &
Wilkins.
Osborn, K.S., Wraa, C.E. & Watson, A.B. (2010). Medical-surgical nursing: preparation for practice. Upper Saddle River: Pearson
Education, Inc.

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