Care Plan

Student: Alexis Gibson Date: 05/12/2020

Course: OB Instructor: Professor Escobar

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

Reason for Admission:

Patient is admitted to hospital for a scheduled c-section related to high blood pressure levels.

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

Diagnoses: gestational hypertension Expected S/S: increased blood pressure, presence of protein in
urine (proteinuria), edema, sudden weight gain, severe headaches,
Pathophysiology: Gestational hypertension is the onset of hypertension
blurred vision, nausea/vomiting, epigastric pain, etc.
without systemic findings like proteinuria or other signs of preeclampsia
after the 20th week of pregnancy (Wilson et al., 2015)). When the systolic
blood pressure is greater than 140mmHg or if the diastolic blood pressure Presented S/S: proteinuria, increased blood pressure, epigastric
is greater than 90mmHg then this could be a concern and is called pain, and edema
hypertension. The pathophysiology is unknown but the theory is that the
“mechanism of reduced placental perfusion inducing systemic vascular
endothelial dysfunction” (Braunthal, S., & Brateanu, A., 2019, p. 4).
When this occurs then in turns into a cascade effect of inflammatory
events which disrupts the balance of certain agiogenic factors. This can
then induce platelets to form which can result into preeclampsia
(Braunthal, S., & Brateanu, A., 2019).

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Risk Factors:
- High blood pressure before pregnancy
- Kidney disease
- Diabetes
- African American ethnicity
- Having multiple pregnancies (Wilson et al., 2015).

Assessment Data
Subjective Data: Patient delivered via c-section and has stated that her pain level is a 9/10 and she has no other complaints.
VS: T : 36.9 C Labs: Diagnostics:
BP: 159/89 - Labs were not available. - Fetal strip taken at 1155 looks to be normal.
HR: 64
RR: 16
O2 Sat: 100% on room air
Pain: 7/10 (before spinal)
The below VS are the most
current VS after c-section was
performed.
T: 36.9 C
BP: 138/85
HR: 95
RR: 20
O2 Sat: 99% on room air

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 Pain: 9/10 (at incision)

Assessment: Orders:
Neuro: - Orders were not available.
- A/O x 4
- LOC = Alert/responsive
Respiratory:
- Unlabored
- Left lower breath sounds = clear
- Left upper breath sounds = clear
- Right lower breath sounds = clear
- Right upper breath sounds = clear
Cardiovascular:
- Pulses = 2+ (palpable)
- Normal sinus rhythm
- Capillary refill is less than 2 seconds
- No murmurs
GI/GU:
- Constipated
- Patient has a foley
- Last void was 1000mL via foley
Patient delivered via c-section:
- EBL: 680mL
- Gender: female
- Date: 04/20/2020

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 - Type: C-Section
Prior to delivery vaginal exam:
- 6cm/80%/-1
BUBBLE he assessment:
- Breast: soft; Nipples: intact; Tenderness present
- Uterus: firm; Midline; fundus located: at umbilcus
- Bowel: Last BM was a few days ago, pt is not passing flatus
- Bladder: pt has a foley
- Lochia: n/a
- Episiotomy/laceration: n/a
Incision site:
- Incision is open to air
- Incision was glued
- Homans sign: negative
- Emotions: pt seems to be very happy

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 Medications
ALLERGIES:
No known drug allergies (NKDA)
Name Dose Route Frequency Indication/Therapeutic Adverse Effects and Side Nursing
Effect Effects Considerations
ketorolac (Toradol) 30 mg IV Q6h hours “Inhibits prostaglandin Side effects: “headache, - “Assess for asthma
PRN for synthesis, producing drowsiness, dizziness, and and uticaria.
moderate to peripherally mediated nausea” (Vallerand, A.H., - Assess pain (note type,
severe pain analgesia” (Vallerand, A.H., Sanoski, C.A., & Deglin, J.H, location, and intensity)
Sanoski, C.A., & Deglin, J.H, 2017, p. 731). prior to and 1-2 hr after
2017, p. 730). This drug helps administration”
to decrease pain. Adverse effects: “prolonged (Vallerand, A.H.,
bleeding time, GI bleeding, Sanoski, C.A., &
oliguria” (Vallerand, A.H., Deglin, J.H, 2017, p.
Sanoski, C.A., & Deglin, J.H, 731-732)
2017, p. 731).

butorphanol (Stadol) 1-2mg/dose IV PRN q4 hr “Binds to opiate receptors in Side effects: “drowsiness, - “Assess type,
for moderate the CNS. Alters the perception constipation, nausea, vomiting, location, and intensity
to severe of and response to painful loss of appetite, and dry mouth” of pain 2 minutes before
pain usually stimuli while producing (Vallerand, A.H., Sanoski, C.A., and 5 minutes after
given during generalized CNS depression” & Deglin, J.H, 2017, p. 1416). - Medication may cause
labor (Vallerand, A.H., Sanoski, sedation so advise
C.A., & Deglin, J.H, 2017, p. Adverse effects: “skin rash, patient to call for
1416). This drug helps to depression, confusion, assistance especially
decrease pain. dysphoria, physical dependence” when ambulating
(Vallerand, A.H., Sanoski, C.A., - Advise patient to
& Deglin, J.H, 2017, p. 1416). change positions
slowly” (Vallerand,
A.H., Sanoski, C.A., &
Deglin, J.H, 2017, p.
1417).
oxytocin (Pitocin) 0.5-1 IV Titrate 1-2 “Stimulates uterine smooth Side effects: “hypotension, - “Advise patient to
unit/min unit/min muscle, producing uterine increase uterine motility, painful expect contractions
q15-60 min contractions similar to those in contractions, and hyponatremia” similar to mentrual

5
 until spontaneous labor. Has
contraction vasopressor and antidiuretic
pattern effects” (Vallerand, A.H.,
reached Sanoski, C.A., & Deglin, J.H,
2017, p. 951). This drug is used
to induce labor or control
postpartum bleeding.
Lactated ringers 1000mL IV Once This is for fluid and electrolyte
replenishment. “Lactated
ringers produce a metabolic
alkalinizing effect. The lactate
ions are metabolized to carbon
dioxide and water. This
requires consumption of
hydrogen cations” (n.d., 2020).
This is used as a source of
electrolytes and water.
(Vallerand, A.H., Sanoski, C.A.,
& Deglin, J.H, 2017, p. 951-
952).
Adverse effects: “coma,
seizures, hypersensitivity, and
decreased uterine blood flow”
(Vallerand, A.H., Sanoski, C.A.,
& Deglin, J.H, 2017, p. 952).
Side effects: “allergic reaction
and phlebitis” (n.d., 2020).
Adverse effects: “hyperkalemia,
burning sensation at injection
site, hypervolemia, and
respiratory distress” (n.d., 2020).
cramps after
administration has
started
- Assess character,
frequency, and duration
of uterine contractions”
(Vallerand, A.H.,
Sanoski, C.A., &
Deglin, J.H, 2017, p.
952-953)
- “Assess for allergic
reaction/hypersensitivity
- Caution should be
exercised when
administering this drug
during labor and
delivery” (n.d., 2020).

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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 intervention Was goal met? Revise the
reasonable, and attainable. interventions. is indicated/therapeutic. plan of care according the
Provide references. client’s response to current
plan of care.
Priority Nursing Diagnosis (including rationale for choosing this as the priority diagnosis)
Risk of infection related to c-section delivery and open to air wound. This was chosen as the priority because the patient had a c-section and the
wound is open to air.

Patient will not be at risk
for infection by the time
she is discharged from the
hospital.
1. The patient will remain
free from infection during
and after her hospital stay.
2. Patient will maintain
good hygiene while in the
hospital by receiving peri
care every day.
3. Patient’s temperature
will remain within normal
range which is 97 F – 99
F.
1. Maintaining good patient
hygiene like cleaning the
perineal area and the wound
site using standard
precautions.
2. Use strict sterile
technique when inserting
urinary catheters and IV
lines.
3. Monitor and document
the patient’s temperature
every 2 to 4 hours.
1. By providing good
patient hygiene “ this can
reduce the risk for
infection” (Phelps, 2017, p.
582).
2. By using sterile
technique this can “reduce
the likelihood of
nosocomial infection”
(Phelps, 2017, p.582).
3. By monitoring the
patient’s temperature, this
can detect “an early sign of
infection” (Phelps, 2017, p.
582).
1. The patient was free
of infection during and
after her hospital stay.
2. Patient maintained
good hygiene during
hospital stay.
3. Patient’s temperature
remained within the
normal range of 97 F –
99 F during her hospital
stay.

Secondary Nursing Diagnosis:

Risk of constipation related to c-section delivery and pain medication administration. This was chosen as the secondary because the patient had
a c-section and is being given pain medication for her pain. Patient is also not mobile after c-section delivery.

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Patient will not be at risk
for constipation by the
time she is discharged
from the hospital.
1. The patient’s bowel
movements will return to
normal by the time the
patient leaves the hospital.
2. The patient will
experience bowel
movements every other
day.
3. Patient will maintain
oral fluid intake of 2,000-
3,000mL daily, unless
contraindicated.
1. Place patient on a
bedpan or commode at
certain times daily.
2. Monitor and record
frequency characteristics
of stools every time bowel
movements occur.
3. Encourage the patient to
intake 2,000 – 3,000mL of
fluid daily.
1. This will help “to aid in
adaptation to routine
physiologic function”
(Phelps, 2017, p. 65).
2. This will help to form a
“monitoring basis of an
effective treatment plan”
(Phelps, 2017, p. 65).
3. This will “ensure
correct fluid replacement
therapy” (Phelps, 2017, p.
65).
1. The patient’s bowel
movements returned to
normal by the time she
was discharged from the
hospital.
2. The patient experienced
a bowel movement every
other day while in the
hospital.
3. The patient drinks 2,000
– 3,000mL of fluid daily.

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.”

References

Braunthal, S., & Brateanu, A. (2019). Hypertension in pregnancy: Pathophysiology and treatment. SAGE Open Medicine, 7,
8
 2050312119843700. https://doi.org/10.1177/2050312119843700

n.d., (2020). Lactated Ringers - FDA prescribing information, side effects and uses. Retrieved from

https://www.drugs.com/pro/lactated-ringers.html

Phelps, L. (2017). Sparks and Taylor's nursing diagnosis reference manual (10th ed.). Hagerstown, MD: Lippincott, Williams &

Wilkins/Wolters Kluwer. ISBN-13: 9781496347817.

Vallerand, A.H., Sanoski, C.A., & Deglin, J.H. (2017). Davis’s Drug Guide for Nurses (15th ed.). Philadelphia, PA: F.A. Davis

Company.

Wilson, D., Hockenberry, M., Perry, S., Alden, K., Lowdermilk, D., & Catherine, M. (2018).

Maternal Child Nursing Care. Retrieved from https://pageburstls.elsevier.com/#/books/9780323549387/