NURS 34000 Nursing Care Plan Cynthia Arce

Patient Initials: SR Admission Date: 10/18/19 Allergies: No Known Allergies

Age: 41 Hx: G3P1010 EDD: 10/25/19 BPA: None BP: 119/82 Wt: 90.7 kg
Last BMI: 31.32 kg/m2 Ht:170.2 cm ABO,RH: O positive GBS: negative Code: Full Narx Score: 000
Newborn Initials: SC Sex: Male Weight: 4500g (9lb, 14.7 oz) Length: 55.9 cm (22”)
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Data: Mother (SR) #1: Mother (SR) #1: Mother (SR) #1: Mother (SR) #1: Mother (SR) #1: Mother (SR) #1:
-“I just feel sore.” Acute pain r/t A Cesarean STG: The patient 1.Assess her pain 1.Interventions 1.Three hours
-“I’m starting to feel disruption of delivery is a will be relieved level regularly, such as giving after surgery her
dizzy and nauseous, I skin, tissue, and surgical and have the quality of her medications, pain was able to
feel like I have to muscle integrity procedure that is controlled pain pain, and manage changing the be decreased,
vomit.” AEB cesarean done to deliver a from nursing her pain with patient’s position and she became
-“Can you please delivery baby. It is not interventions 3 different and instructing the comfortable. As
move me slowly (Doenges, 2016). always planned hours after interventions. patient to use a an intervention,
because I get and it can cause surgery. 2. Monitor vital pillow on her she ended up
nauseous easily.” different adverse signs. abdomen when using a pillow on
reactions. LTG: The patient 3. Provide a she coughs or her abdomen
Objective Data Depending on the will experience comfortable moves helps the when she
Mother (SR): mother’s pain reduced pain environment for patient relieve her coughed to help
Medical Problems: level, and due to each day for the mother. pain (Cheifetz, relieve her pain.
-Hx of low transverse the disruption of about 6 weeks 2010). Therefore, the
cesarean section (had skin, tissues, and (depending on 2. It is important to goals were met.
Ancef, TXA, spinal muscles, there the mother’s monitor the
anesthesia, foley, can be lots of pain pain level) after patients vital signs
abdominal prep, that the mother the procedure. after surgery
SCD’s). feels (Keag, because a mother
-Advanced maternal 2018). can experience
age in multigravida, changes in blood
panorama low risk. pressure, pulse
-Macrosomia changes,
affecting respiratory
management of changes and many
mother in third other changes that
trimester, EFW @35 need to be
weeks 97%. watched (Cheifetz,
-Polyhydramnios 2010).
affecting pregnancy 3. Providing a
in third trimester, AFI comfortable
28 cm. environment helps
-39 weeks of the patient stay
gestation of calm and relaxed
pregnancy. (Cheifetz, 2010).

Surgical History Mother (SR) #2: Mother (SR) #2: Mother (SR) #2: Mother (SR) #2: Mother (SR) #2: Mother (SR) #2:
-Anesthesia, C- Nausea r/t Nausea is the STG: The patient 1.Administer and 1. Administering The patient was
Section gastrointestinal unpleasant will be able to monitor the antiemetic’s to the able to manage
-Breast biopsy irritation AEB feeling in the back manage her patient’s patient and her nausea,
-Extraction erupted subjective data of the throat or nausea from response to the monitoring her however, she still
tooth/EXR of her saying she stomach, that medications medications that response is very had a little bit of
-Rhinoplasty feels nauseous, may result in right after were given to important because nausea by the
she felt nauseous vomiting. Nausea surgery. treat her nausea. we need to assess end of our shift.
-former smoker after her is common in post The medication that the We were able to
-alcohol use: previous operative patients LTG: The patient that she was medications help prevent her
occasionally, not cesarean section and it is mostly will be free of given was helped the feelings nauseousness by
currently due to the caused by effects feelings of REGLAN as an of nausea to go taking
anesthesia from anesthesia nausea and antiemetic. away. REGLAN is precautions such
Labs (Doenges, 2016). (Shaikh, 2016). vomiting by the 2.Identify the an antiemetic and as pushing the
-HGB: 12.5 Approximately, end of our shift. situations that the is commonly given bed slow, and
-Hematocrit: 36.8 30% of all patient perceives to women after c- keeping the head
-Platelet count: 226 patients suffer that induces her sections who of the bed low.
-WBC: 12.17 from nausea and feelings of experience nausea -REGLAN
vomiting in the nausea. (Jelting, 2017). administered
OB History postanesthesic
-Outcome: term period, where the 3.Determine if the 2.By finding out -Spinal anesthesia
-Date: 08/19/17 first six hours nausea is what causes her administered
-GA: 41w0d have the highest potentially self feelings of nausea,
-Weight: 4.082 kg (9 incidence (Jelting, limiting and/or we may be able to
lbs). 2017). mild or is severe control the
-Sex: Male and prolonged. situation or
-Delivery: CS-L Tranv prevent it from
-Anesthesia: Spinal happening. For
-Complications: example, the
failure to progress in patient stated that
second stage, fetal she didn’t want to
distress affecting be moved fast
care. because she will
feel nauseous,
Lines/Drains/Airways therefore, we
-Peripheral 10/18/19 moved her slowly
on admission short to prevent it
left forearm 18 gauge (Doenges, 2016).
3.It is important to
Fetal HR: find out the
-@0722 severeness of the
-Baseline rate: 120 nausea because
bpm nausea affects
-Variability: 6-25 bpm fluid and
-Accelerations: electrolyte balance
Present and nutritional
-Decelerations: None status (Jelting,
-FHR Category: 2017).
Category I

Meds
-Cefazolin Iv
piggyback 2 g in D5W
100 mL (ANCEF)
-Metoclopramide HCL Baby (SC): Baby (SC): Baby (SC): Baby (SC): Baby (SC): Baby (SC):
10 mg injection Unstable blood Hypoglycemia is STG: The patient 1.Give the baby 1.Administering The baby was
(REGLAN) glucose level r/t the most will have a stable formula if the formula to the able to get his
-Oxytocin 10 units iv inefficient common glucose level by baby is not baby is done if the glucose level
bolus (POSTPARTUM) blood glucose metabolic the end of our getting enough baby has a really back to normal
(PITOCIN) from problem in shift. breast milk. low glucose level by the end of
-Sodium citrate citric breastfeeding/ newborns. This 2. Assess the and needs to get our shift. The
acid 500, 334 mg/ 5 from mom metabolic LTG: The patient baby’s glucose the level up fast baby’s glucose
mL, 30 mL (BICITRA) AEB: glucose problem is seen a will have a stable level before and (Wight, 2014). went from a 34
-Tranexamic acid 100 level of 34 lot in small or big glucose level all after 2.The baby’s mg/dL to 40
mL (CYCLOKAPRON) mg/dL after for gestational the way until the administering glucose level mg/dL after
-lactated ringers breastfed a few age babies, and baby’s first check formula. should be assessed drinking 10 oz,
infusion 125 mL/hr times (Doenges, preterm infants up. 3. Assess the before and after then 15 oz more
continuous infusion 2019). (Harriman, 2018). mother’s he was given of Similac,
education on the formula so we can which was a
Uterine Activity importance of see if the glucose
higher level of
-Mode: External toco maintaining a level increased or
glucose.
-Contractions: normal glucose not from the
-the mother’s
Regular level for formula (Wight,
plan is to
-Cont. Freq (min): 1-4 newborns. 2014).
breastfeed and
-Cont. Quality: Mild 3. If the mother
-Uterine Tachysystole does not know
give formula
Present?: No about glucose
-Uterine Palpation levels in babies
w/Relaxation: Soft, and how
non tender important it is for
baby’s to have a
Vitals normal glucose
-@6:30 level, she should
-Temp: 36.5 C, be educated so she
temporal can help in the
-Pulse: 90 care of her baby
-Resp: 16 (Wight, 2014).
-BP: 119/82 (83)
-SPO2: 97, RA
-Pain: 2, tightness in
abdomen, acceptable
level 2, awake

Breastfeeding
Experience
-had previous
breastfeeding
experience
-no difficulty of
breastfeeding

Assessment
-Psychosocial: WNL
-Neurologic: WNL
-Vascular: WNL
-Functional: WNL
-Respiratory: WNL
-Genitourinary: WNL
-Gastrointestinal:
WNL
-Cardiac: WNL
-No edema
-Braden Scale: 23
-Hester Davis Falls
Risk Assessment: 3

Informed Consents
-blood transfusion, C-
section delivery,
tubal ligation

Patient Plans/Other
-plans to breastfeed
-mom lost 700 cc of
blood during newest
C-section

Baby (SC):
Subjective Data
-Crying when he
came out of the
womb and when
pricked with a
needle.
-Moved when we
touched him.

Objective Data
-Head circumference:
38.5 cm
-delayed cord
clamping x60 sec,
kiwi on 0921 off at
0922
-NB had security
band on and sensor

Baby Delivery
-Time head delivered:
0922
-Birth time: 0922
-C-section without
labor
-Rupture date: 10/18
-Rupture time: 0921
-Type: AROM
-Fluid color: clear
-Anesthesia: spinal
-FHR after anesthesia,
before c/s incision:
115
-code pink, no
resuscitation needed
-APGAR: 8 & 9
-Specimens: Fallopian
tubes R & L

Placenta Delivery
-Delivery time: 0925
-Placenta disposition:
discarded

Cord
-3 vessels
-cord blood obtained

Glucose Levels
-Baby’s blood sugar
was >40 (34) so they
gave him Similac, he
drank 10 oz at first
(@11:15), then 15 oz
more (@12:15). It
then went up to 40.

Assessment
-NIPS: 1
-Resp: unlabored,
grunting, symmetrical
chest excursion
-Vitals @12:00
-Temp: 37 C
-Pulse: 128
- Resp: 50
- Spo2: 99
-swaddled
-cry appropriate for
gestational age
-Neuro maturity
scale: 18
-feeding plan: human
milk and formula
-kangaroo initiated in
recovery room.

Medications
-gave Hep B vaccine
0.5 mL injection
(ENGERIX-B)
-sucrose 24% 0.1 mL
oral solution (SWEET-
UMS).
-Erythromycin 5 mg/g
(0.5%) ophthalmic
ointment, both eyes
-phytonadione
(Vitamin K1) 1 mg/
0.5 mL 1 mg ampule
(Vitamin K Neonatal)
intramuscular once.
Narrative:

Overall my patient did well with her procedure. Both the mother and the baby didn’t have serious problems during or after the procedure. The
mother dealt with her feelings of nausea and baby very well. Four other nursing diagnoses for the mother would be, Risk for infection r/t tissue
trauma AEB C-section, Risk for maternal injury r/t effects of medication AEB nauseousness from the anesthesia, Readiness for enhanced
breastfeeding r/t mother’s desire to enhance ability AEB the mother saying she wants to continue breastfeeding along with giving formula to her
baby, and Risk for falls r/t postoperative recovery period AEB C-section and pain. One more baby diagnosis would be Risk for ineffective
thermoregulation r/t immature temperature control AEB being a newborn with little subcutaneous fat (Doenges, 2019).

References

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nurses pocket guide: diagnoses, prioritized interventions, and rationales.
Philadelphia: F.A. Davis Company.
Harriman, T. L., Carter, B., Dail, R. B., Stowell, K. E., Harris-Haman, P. A., & Zukowsky, K. (2018). Golden Hour Protocol for
Preterm Infants: A Quality Improvement Project. Advances in Neonatal Care (Lippincott Williams & Wilkins), 18(6), 462–
470. https://ezproxy.hiram.edu:2271/10.1097/ANC.0000000000000554
Jelting, Y., Klein, C., Harlander, T., Eberhart, L., Roewer, N., & Kranke, P. (2017). Preventing nausea and vomiting in women
undergoing regional anesthesia for cesarean section: challenges and solutions. Local and regional anesthesia, 10, 83–90.
doi:10.2147/LRA.S111459
Keag, O. E., Norman, J. E., & Stock, S. J. (2018). Long-term risks and benefits associated with cesarean delivery for mother, baby,
and subsequent pregnancies: Systematic review and meta-analysis. PLoS medicine, 15(1), e1002494.
doi:10.1371/journal.pmed.1002494
Shaikh, S. I., Nagarekha, D., Hegade, G., & Marutheesh, M. (2016). Postoperative nausea and vomiting: A simple yet complex
problem. Anesthesia, essays and researches, 10(3), 388–396. doi:10.4103/0259-1162.179310
Wight, N., Marinelli, K. A., & Academy of Breastfeeding Medicine (2014). ABM clinical protocol #1: guidelines for blood glucose
monitoring and treatment of hypoglycemia in term and late-preterm neonates, revised 2014. Breastfeeding medicine : the
official journal of the Academy of Breastfeeding Medicine, 9(4), 173–179. doi:10.1089/bfm.2014.9986