Care Plan

Student: Jessica Evans Date: 12/4/2018

Course: NSG432CC Instructor: Christina Scott

Clincial Site: Banner Del Webb- Postpartum Unit Client Identifier: SR Age: 21

Reason for Admission: Patient came into the hospital 11/29/2018 with suspicion of her water breaking. She is now one day postpartum.

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

Pregnancy/Postpartum- A fetus grows inside a woman’s uterus Fatigue
with an increase of hormones to sustain pregnancy. All nurtients Pain
from mother go to fetus through the placenta as well as provides
the fetus oxygen. A woman is at risk of infection and hemorrhage Hormonal
during the postpartum phase, after giving birth.

Assessment Data
Subjective Data: Patient came in 11/29/2018 with leaking fluids and it was confirmed to be rupture of membranes. She was 39 weeks
gestation and had her baby boy 11/30/2018 at 1042. She is now in the postpartum unit.
VS: Mother’s T : 36.1 Celsius Labs: Morther’s- Diagnostics:
BP: 117/76 WBC: 9.7 K/mm3 None for Mother and Baby.
HR: 96 HGB: 11.9 g/dl
RR: 16 Blood Type: O Positive, negative antibodies
O2 Sat: 98%
© 2018. Grand Canyon University. All Rights Reserved. Rev 2.17.18
Infant’s: T: 36.8 Celsius Infant’s-
HR: 140 Cord Blood Type: A Positive
RR: 52

Assessment: Orders:
MOTHER: MOTHER:
Alert and Oriented times four. Behavior is appropriate for situation. Full code.
Unlabored, clear breath sounds. Respiration rate is 16 breaths per Breast Pump electric.
minute. Oxygen satuation is 98%, she is on room air.
Apply cold therapy.
She has a regular heart rhythm, within normal limits as S1 and S2
Vital signs Q4H.
sounds were noted. Heart rate is 96 beats per minute. Her blood
pressure is 117/76. No edema noted. Her capillary refill is less than two Discontinue all anesthesia.
seconds and 2+ pulses at radial and pedal pulses noted.
Regular diet.
Abdomen is round with bowel sounds present. Palpation noted as soft.
VTE Prophylaxis Advisor.
Voids with no difficulties. Bowel movement was earlier in day.
INFANT:
Steady gait.
Admit to inpatient.
Skin color is usual for ethnicity and warm, dry, and intact.
Complete consent for circumcision.
0805- Pain was located at lower abdomen 7/10.
If ineffective breastfeeding, supplement with available 22 calories.
1243- Pain was at 2/10.
If baby show signs of hypoglycemia, initiate phases under
INFANT: management of situation.
Alert and responsive. Negative signs for pain and agitation. If jaundice, activate bilirubin management.
Unlabored, clear breaths sounds. Respiration rate is 52 breats per Newborn Hearing screen.
minute. Baby is on room air.

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Baby has a regular heart rhythm, S1 and S2 sounds noted. Heart rate is Obtain weight.
noted at 140 beats per minute. Nail bed color is described as pink and
RSP oxygen to maintain above 90%.
capillary refill is less than 2 seconds. No edema noted.
Abdomen is round and soft. Bowel sounds are present. Stool output is
one time for the day.
Eliminates in diapers and has a clear urine description.
Skin color usual for ethnicity and warm, dry, and intact. Mongolian
mark is noted at buttocks.

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 Medications
ALLERGIES: No known allergies for both Mother and Baby.
M= Mother B= Baby
Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing
Effect Considerations
M. Ibuprofen 600mg= 1 Oral Q6H, PRN= Treatment for mild to GI distress, raised liver Check liver labs
tablet Pain/Temperature moderate pain. (Patient enzymes, and before and after
experiencing pain in constipation. administration.
lower abdomen)
M. Zolpidem 5mg= 1 Oral QBedtime, PRN= Treatment of insomnia. Dizziness, drowsiness, Rise slowly when
tablet Insomnia (Patient was experiencing nausea, vomiting, and changing
insomnia) dry mouth. positions.
M. Multivitamin, 1 tablet Oral Daily To provide needed Stomach cramps, Provide vitamin
Prenatal vitamins to mother and nausea, and constipation. with food as an
baby. option of
administration.
M. Docusate 100mg= 1 Oral BID, PRN= Treatment of Stomach pain, diarrhea, Provide sufficient
capsule constipation constipation. (Patient was and cramping. amount of fluids.
experiencing some mild
constipation.)
M. MMR Vaccine 0.5ml SubQ 1 Dose Prevention of mumps, Short term rash, fever, Take temperature
measles, and rubella. and analphylaxis. before and after
(Patient had low titers administration.
and need for vaccination)
B. Sucrose 0.1ml Oral PRN For any invasive, acute No side effects. Give during any
procedural pain in well painful procedures
neonate. to infant.
B. Zinc Oxide 1 app Topical PRN Prevention of diaper rash. Itching, swelling, and Assess respirations
trouble breathing and signs of
respiratory distress
before and after
administration.

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 Nursing Diagnoses and Plan of Care
Goal Expected Outcome Intervention(s) Rationale Evaluation
Client or family focused. Measurable, time-specific, Nursing or interprofessional Provide reason why Was goal met? Revise
reasonable, and attainable. interventions. intervention is the plan of care
indicated/therapeutic. according the client’s
Provide references. response to current plan
of care.
Priority Nursing Diagnosis: Acute Pain related to postpartum as evidenced by pain rating of 7/10.
Patient will demonstrate - Provide a noiseless, lightly - This offers a place to Yes, patient had
Patient will be pain free relaxation skills and other lit room. manage her pain without demonstated a variety of
and identify mutliple techniques to manage pain - Teach nonpharmalogical distractions and focus on relaxation skills that
techniques to manage pain. by discharge. methods to manage pain her relaxation techniques. helped her manage her
such as: guided imagery, - This helps her manage pain she felt after giving
massage, and deep her pain without the use of birth.
breathing. pharmalogical methods.

Secondary Nursing Diagnosis: Knowledge Deficit related breastfeeding as evidenced by first baby and never breastfeeding before.
Patient will be able to Patient will demonstrate Consult with a lactation This is an expert on Yes, patient described and
breastfeed her baby with current latch describe how nurse. breastfeeding who will sit demonstrated the correct
no problems. to correctly breastfeed her Teach patient on the down with the patient and ways to breastfeed her
baby. correct holds, latch, and show her what she needs baby, so he gets enough
how to know when baby is to do. nutrients.
getting enough. This educates the patient
Assess baby’s diapers to on the best way to
determine if baby is breastfeed, so her baby is
getting enough food. growing and getting
Educate patient on how to nutrients.
keep milk supply This helps determine
whether baby is getting
enough food.
This teaches the patient
the basics to maintain her
milk supply for as long as
she wants to breastfeed.
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 References
Brown, H. (2018). Physiology of Pregnancy. Retrieved from https://www.merckmanuals.com/professional/gynecology-and-
obstetrics/approach-to-the-pregnant-woman-and-prenatal-care/physiology-of-pregnancy