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Care Plan

Student: Jessica Evans Date: 3/28/2019

Course: NSG444CC Transition to Practice Residency Instructor: Christina Scott

Clincial Site: Abrazo West- Labor and Delivery Client Identifier: NM Age: 28

Reason for Admission: NM is admitted for an elective induction because she is past 40 weeks gestation in her pregnancy.

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


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

Assessment Data
Subjective Data: The patient is here for an elected induction due to being post-term in her pregnancy. This is her first child and second
pregnancy. Her first pregnancy was a SAB at 8 weeks in 2008. She plans for an epidural and to breastfeed.
VS: T : 97.5F (Oral Route) Labs: Diagnostics:
BP: 120/85 Blood Type/Rh: A Positive None Found.
HR: 75 RPR: Negative

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RR: 16 HIV/Chlamydia/Herpes: Negative
O2 Sat: 99% GBS: Negative
WBC: 10.2
RBC: 4.52
Platelet: 216

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Assessment: Orders:
Patient is alert and oriented times four. She is awake and can hold a OB Basic Administration Information
conversation. Her pupils are brisk, equal, round, reactive, regular, and
Fetal Monitoring
open spontaneously.
Fetal Scalp Electrode
Her upper and lower extremities move against resistance and are strong
and equal. Rountine Vital Signs
Her breath sounds are clear and unlabored. Denies cough and she is on Activity as Tolerated
room air. Her respirations are 16 breaths per minute and her oxygen
saturation is 99%. Clear Liquid Diet
Labor Induction
Her heart rate and rhythm are regular and within normal limits. S1S2
sounds were noted. Her heart rate was 75 beats per minute and her Peripheral IV Insertion
blood pressure was 120/85. Edema was noted but not pitted. It was
located in her lower extremities. Vaginal Examination

Her pulses are 2+ at the radial location. Her capillary refull is less than Verify Consent
3 seconds. O2 Therapy
Her abdomen is round with bowel sounds present and within normal Epidural/Epidural Protocols
limits. Her last bowel movement was 3/28/2019 in the morning. Her
diet is clear liquids. No tenderness noted. Straight Indwelling Catheter

She voids on her own and her urine is clear. CBC

Her skin color is appropriate for ethnicity, intact, cool, and dry. She RPR Test
does have a tattoo on her right foot.
She has an IV on her right hand and an 18 gauge.
She ambulates on her own and a steady gait.

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FETAL HEART TONES
1241: Heart rate is 142 beats per minute. Moderate variability with
accelerations.
Mom is 2cm dilated, 50% effaced, and -2 station.
1450: Heart rate is 144 beats per minute. Moderate variabilty with
acceleration.
Mom is dilated 5cm, 70% effaced, and -1 station.
1601: Heart rate is 140 beats per minute. Moderate variability with
accelerations.
Mom is dilated to 6cm, 80% effaced, and -1 station.

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Medications
ALLERGIES: No Known Allergies
Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing
Effect Considerations
Lactated Ringers 1000ml IV Bolus 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.
Misoprostol (Cytotec) 50mcg PO Q4H Used to induce labor. Diarrhea, nausea, Check dilation
Patient is admitted to headache, and stomach before and after
induce labor. cramps 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 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: Acute Pain related to contractions as evidenced by pain rating of 3/10.
Patient will state a pain Teach patient relaxation This will help the patient Yes, the patient met the
Patient will be free of any rating of 2/10 or lower by techniques: meditation or manage the pain without goal when he stated a
pain. end of shift. guided imagery. the use of pharmacological pain rating of 2/10 by
Provide a dark, quiet room. methods. end of shift.
This will help the patient
focus on relaxation
techniques to help with the
pain.

Secondary Nursing Diagnosis: Knowledge Deficit related to childbirth as evidenced by lack of childbirth classes.
Patient will understand Patient will demonstrate Educate patient on This will help patient Yes, patient met the goal
what to do during labor sufficient knowledge on appropriate breathing manage her pain before because both were free of
and delivery. what to do as she labors techniques as she labors. desired eipdural. infection by discharge.
and give birth. Educate patient on This will help the patient
different options regarding make educated decisions
pain relief, birthing on what she wants for pain
process, and induction relief and what to expect.
process.

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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.”

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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