Care Plan

Student: Jessica Evans Date: 3/30/2019

Course: NSG444CC Transition to Practice Residency Instructor: Christina Scott

Clincial Site: Abrazo West- Labor and Delivery Client Identifier: DR Age: 24

Reason for Admission: DR is admitted for an elective induction due to her being 40 weeks 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 elective induction since she is 40 weeks gestation of her pregnancy. She is a G3P2 with her first
pregnancy in 2015 where she gave birth vaginally to a baby boy with no complications. Her second pregnancy was with a baby girl and she
gave birth vaginally with no problems. Both babies were 7 pounds and 2 ounces. She denies any problems during her pregnancy and any
medical history. However, she had limited prenatal care since she did not start the care until after 20 weeks. She plans for an epidural birth and
bottle feeding. Her urine drug screen showed THC positive.

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VS: T : 98.7 F (Oral) Labs: Diagnostics:
BP: 124/70 Blood Type: A+ None Found.
HR: 71 Antibody Screen: Negative
RR: 16 Hgb: 12.3
O2 Sat: 100% Hct%: 34.5
Platelets: 301
WBC: 10.3
RBC: 3.87
GBS: Negative
RPR: Negative
UDS: Positive THC

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Assessment: Orders:
Alert and Oriented times four. Her pupils are brisk, equal, round, and OB Basic Administration Information
reactive. They open spontaneously. Her upper and lower extremities
Fetal Monitoring
move against resistance and are equal. However, after her epidural at
1415 3/30/2019, her lower extremities are weak and do not move Fetal Scalp Electrode
against resistance.
Rountine Vital Signs
Her breath sounds are clear and unlabored. She denies any cough. She
is on room air with an oxygen saturation of 95%. However, after her Activity as Tolerated
epidural and her labor progression at 3/30/2019 1459, she is on a simple Clear Liquid Diet
face mask with 15ml of oxygen. Her oxygen saturation then was 100%.
Labor Induction
Her heart rate and rhythm are regular and within normal limits. S1S2
sounds noted. Her heart rate was 71 beats per minute. Her blood Peripheral IV Insertion
pressure was 124/70. Slight edema noted on her lower extremities. Vaginal Examination
Pulses were taken at her radial and dorsalis pedis. They were 2+. Her Verify Consent
capillary refill was less than 3 seconds.
O2 Therapy
Her abdomen was round with bowel sounds noted and within normal
limits. Her last bowel movement was earlier in the day of 3/30/2019. Epidural/Epidural Protocols
No tenderness noted. Her diet is clear liquids and then ice chips after Straight Indwelling Catheter
her epidural 1415 3/30/2019.
CBC
She voided on her own. After her epidural 3/30/2019 1415, she had a
foley catheter placed. It was a 16F and it was inserted 3/30/2019 at RPR Test
1443. Her urine is clear and slightly yellow.
Pericare was performed before and after the insertion of the epidural
along with her chucks changed as well 3/30/2019 1435 and 1500.
Her skin color is appropriate for ethnicity, intact, warm, and dry. Her IV
was in her left hand, however, there were signs of it starting to infiltrate

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because of the redness that appeared along her vein and her arm was
cool to the touch.
As a result, her IV was removed on her left hand and a new peripheral
IV was inserted on the right hand 3/30/2019 1503. This was an 18
gauge.
She ambulated on her own and had a steady gait. However, after her
epidural 3/30/2019 1415, she was bed bound and could not feel her
legs.
FETAL HEART TONES
1340: Fetal heart rate average is 140 beats per minute. Moderate
variability with accelerations present. Category I. She is contractiing
every 3-4 minutes.
Mom is 4-5 centimeters dilated, 80% effaced, and -1 station.
SROM at 1341 and it was clear.
1530: Fetal heart rate average is 130 beats per minute with moderate
variability and accerlerations present. Category I between contractions.
However, during contractions fetal heart rate average cannot be
determined because of variable decelerations. Category II. She is
contracting every 2-3 minutes.
Mom is 8 centimeters dilated, 90% effaced, and 0 station.
INTERVENTIONS FOR HER VARIABLE DECELERATIONS:
Oxygen Increased. Simple face mask, 15ml 1459
New IV Right Hand, 18 gauge for an increase of fluids 1503
Change to a left lateral position 1504

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Fetal Scalp Electrode Inserted 1505
Doctor Informed 1508
Internal Contraction Monitor Inserted 1545

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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 x2 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.
Cervadil 10mg Vaginal Once Used to help dilate the Nausea, fever, vomiting, Check dilation
Scheduled opening of the cervix. diarrhea, and abdominal before and after
Patient is being induced pain. administration.
for labor.
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)

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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.”

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 labor contraction as evidenced by pain rating of 8/10.
Patient will exhibit Patient will demonstrate Provide a quiet, dark room. This allows the patient to Yes, the patient met the
relaxation techniques to appropriate relaxation Provide an appropriate focus on managing her goal by demonstating a
manage her pain. 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 infection.
Patient and infant will Patient and Infant will Attain a sterile field for This limits the amount of Yes, patient met the goal
remain healthy and display signs of vaginal exams and limit bacteria that can be because both were free of
uninjured. appropriate healing and the number of exams. introduced to patient and infection by discharge.
health by discharge. Assess continous fetal infant.
monitoring. This allows for early
Assess patient for signs of detection of signs of
infection per protocol. distress in patient and
infant.

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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