Care Plan

Student: Jessica Evans Date: 4/4/2019

Course: NSG444CC Transition to Practice Residency Instructor: Christina Scott

Clincial Site: Abrazo West- Labor and Delivery Client Identifier: EO Age: 27

Reason for Admission: EO is admitted onto the unit for an elective induction.

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

Pregnancy: A fetus grows inside a woman’s uterus with an Excessive thirst and hunger
increase of hormones to sustain pregnancy. All nurtients from Excessive urination
mother go to fetus through the placenta as well as provides the
fetus oxygen. The fetus is surrounded by a fluid-filled sac that Fatigue
cushions it. At the start of labor, it typically ruptures. An induction High Blood Sugar
of labor is giving the woman medications to start her labor and
intensify her contractions, so she dilates to 10 centimeters. Cramping, Intermittent

Gestational Diabetes: a condition during pregnancy where the Fatigue

condition in which a hormone from the placenta prevents the body Nausea
to effectively use insulin, causing high sugars.
Tightening of abdomen

Assessment Data
Subjective Data: EO is a diet controlled gestational diabetic and was admitted for an elective induction. She is a G2P1 with her first pregnancy
in 2015 where she gave birth vaginally to a baby girl. She denies any problems or complications. She was diagnosed with gestational diabetes
during this pregnancy and it is diet-controlled. She denies any medical history. She has her husband and mom in the room with her. She planned
for an epidural for the birth and to breastfeed and bottle-feed.
© 2018. Grand Canyon University. All Rights Reserved. Rev 2.17.18
VS: T : 99.5F Labs: Diagnostics:
BP: 109/60 Blood Type: O Positive None Found.
HR: 102 Hgb: 13.5
RR: 16 Hct%: 38.8
O2 Sat: 98% Platelets: 191
WBC:11.2
RBC: 4.64
GBS: Positive
RPR: Negative

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Assessment: Orders:
Patient is awake and oriented times four. Patient can carry a OB Basic Administration Information
conversation with nurses and family. Her pupils are brisk, equal, round,
Fetal Monitoring
and regular. She opens her eyes spontaneously.
Fetal Scalp Electrode
Her upper extremities move against resistance and equal. Her lower
extremities are unequal and weak due to her epidural that was placed Rountine Vital Signs
4/3/2019 at 2312.
Activity as Tolerated
Her breath sounds were clear and unlabored. She denies any cough. She
Clear Liquid Diet
was placed on oxygen via face mask on 15ml. She was given oxygen
due to fetal heart rate monitoring. Her oxygen saturation is 98%. Her Labor Induction
respirations are 16 breaths oer
Peripheral IV Insertion
Her heart rhythm was regular with a slightly elevated heart rate at 102
Vaginal Examination
beats per minute. S1S2 sounds were noted. Edema was absent. Her
blood pressure was 109/60. Verify Consent
Her pulses were noted and 2+ and felt at her dorsalis pedis and radial O2 Therapy
locations. Her capillary refill was less than three seconds.
Epidural/Epidural Protocols
Her abdomen is round with bowel sounds noted and within normal
limits. No tenderness noted and her diet is ice chips. Straight Indwelling Catheter
CBC
She has a foley catheter and the size is 16 French, inserted at 2/4/2019
at 0010. Her urine is dark yellow with red particles. RPR Test
Pericare is done at 4/4/2019 at 0845 with underpad changed.
Her color is appropriate for ethnicity and is warm, dry, and intact. She
has a peripheral IV on her left wrist with an 18 gauge.
She is on bedrest with an unsteady gait due to her epidural inserted at
4/3/2019 at 2312.

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FETAL HEART TONES
0600: Fetal heart rate average is 160 beats per minute with moderate
variability and absent accelerations. Patient is contracting every 2-3
minutes.
Mom is dilated 8 centimeters, 80% effaced, and 0 station.
SROM is spontaneous at 0630 and is clear.
0800: Fetal heart rate average is 160 beats per minute with minimal
variability with absent accelerations. There are variables present. She is
contracting every 2 minutes.
Mom is dilated 9 centimeters, 100% effaced, and 1 station.
INTERVENTIONS:
Oxygen placed with simple face mask at 15ml and sat up in a high
fowler’s position.

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 Medications
ALLERGIES: No known drug allergies.
Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing
Effect Considerations
Lactated Ringers 1000ml IV Continuous Used to hydrate patient. Fluid retention and Check blood
Patient requests an hypertesion. pressure before and
epidural when pain is after administration
high, so fluids are
necessary.
Ondansetron (Zofran) 4mg= 2ml IV Push PRN Q6H Treatment and prevention Lightheadedness, Determine scale of
of nausea and vomiting. headache, diarrhea, and nausea before and
(Patient is prescribed fever. after administration
Zofran in case of nausea
or vomiting)
Oxytocin 2mu/min IV Increase Used to induce labor. Intense contractions, Check dilation
2mu/min Patient was admitted to nausea, cramping, and before and after
every 30 induce labor. stomach pain. administration.
minutes

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Goal
Client or family focused.
Priority Nursing Diagnosis:
Patient will exhibit
relaxation techniques to
manage her pain.
Nursing Diagnoses and Plan of Care
Expected Outcome Intervention(s) Rationale Evaluation
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.
Acute Pain related to labor contraction as evidenced by pain rating of 6/10.
Patient will demonstrate Provide a quiet, dark room. This allows the patient to Yes, the patient met the
appropriate relaxation Provide an appropriate focus on managing her goal by demonstating a
techniques by the end of temperatured room. pain. variety of relaxation
shift. Teach relaxation techniques This allows the patient to techniques.
such as: guided imagery, relax and manage her pain
massage, and music. without being too cold or
hot.
This helps manage her pain
without pharmalogical
measures.

Secondary Nursing Diagnosis: Risk for fetal injury related to elevated maternal blood glucose.
Patient and infant will Patient and Infant will Assess fetal heart tones This monitors fetal health Yes, patient and infant
remain healthy and display signs of and movement. as it can be negatively were free of injury at
uninjured. appropriate health by Educate the importance of affect the fetus. discharge.
discharge. controlling diet. This will improve the
Assess urines for ketones. blood sugar of patient and
baby.
Ketones can negatively
affect the fetus, so it is

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important to monitor
ketones.

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 References
Mayo Clinic. (2018). Water Breaking: Understand This Sign of Labor. Retrieved from https://www.mayoclinic.org/healthy-
lifestyle/labor-and-delivery/in-depth/water-breaking/art-20044142
John Hopkins Hospital. (2019). Gestational Diabetes. Retrieved from https://www.hopkinsmedicine.org/health/conditions-and-

diseases/diabetes/gestational-diabetes