Care Plan

Student: Gracie Hertel Date: October 7, 2019

Course: NSG-432CC Instructor: Professor Schnieder

Clincial Site: St. Joseph’s Hospital and Medical Center Client Identifier: B.A. Age: 29

Reason for Admission: Patient came into OB triage at 0600 for a scheduled cesarean birth on 10/7/19. The patient’s prenatal labs came back
negative for any bacterial or viral strains, with her blood type coming back as AB+. She is at risk for postpartum depression due to her past
medical history of depression. She is having a baby girl, who has hydrocephalus and she is in the breech presentation. The patient went into
surgery at 0800 and delivered her baby at 0855. She had a vertical incision done on her uterus and a transverse incision on her abdomen. She
tolerated the surgery well. The patient was recovering in the OB recovery room until she was transferred to the postpartum unit, while her baby
is in the neonatal intensive care unit.

Medical Diagnoses: (Include Pathophysiology and Risk Factors):
Cesarean birth –
A cesarean birth is the birth of the fetus through a transabdominal incision
of the uterus. This type of birth can be planned (scheduled) or unplanned.
The purpose of this type of birth is to preserve the well-being of both the
mother and the baby. It is usually considered the best choice when any
maternal or fetal complications exist. A cesarean birth is done by creating
a incision into the lower uterine segment. Indications for this type of birth
include any specific, maternal cardiac disease, malpresentation of the
fetus, active matermal herpes infection, cephalopelvic disproportion,
placental abruption, placenta previa, and history of cesarean birth (Perry
et al., 2018).
Clinical Manifestation(s): For a cesarean birth, depending if it
is planned or unplanned, the patient will experience different
signs of symptoms. In this case, the patient did not have a lot of
symptoms because she was a planned cesarean birth.
Therefore, she did not expereince any specific normal signs and
symptoms of labor. For the list of general S/S, I will use the
normal S/S one would see in a laboring patient.
Patient’s clinical manifestations – contractions every 3-4 minutes
lasting 20-30 seconds, cramping
Other clinical manifestations - Rupture of membranes, dilation
and effacement of cervix, bloody show, nausea/vomiting, lower
back pain, cramping.

© 2018. Grand Canyon University. All Rights Reserved. Rev 2.17.18

Risk Factors – past cesarean birth done in the past, nonreassuring fetal
status, cephalopelvic disproportion, placental abruption, placenta previa,
malpresentation of baby.

Assessment Data
Subjective Data: Patient states she is in a significant amount of pain, she states it to be a 6/10. She also states that she is starting to feel
anxious.
VS: morning vitals Labs: Diagnostics:
T: 97.2F All labs were within normal limits. No diagnostics were done at this moment in time.
BP: 120/82
HR: 63
RR: 12
O2 Sat: 985 on room air

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Assessment: Orders:
PMH – neuropathy, smoker, substance abuse (opioids), hepatitis C,  Monitor vital signs every 1 hour
depression, anxiety.  Clear liquid diet
B – Breasts are soft and filling with no cracking or bleeding; colostrum  Monitor intake and output
is present.
 Assess pain every 1 hour
U – uterus is firm; approximately 1cm underneath the umbilicus. There
are no signs of excessive bleeding or blood clots.
B – bladder is nondistended; patients has a Foley catheter placed. It is a
14 French and she had an output of 300mL at 1100. Urine is yellow and
clear.
B – bowel; patient has normoactive bowel sounds with no distension;
last BM was on 11/6.
L – lochia is rubra and scant; there are not clots present or foul smell.
E – patient did not have an episiotomy done since she had a cesarean
birth.
H – Homan’s sign is negative; patient has no warmth, tenderness, or
swelling in her legs bilaterally.
E – emotional status; patient is excited that her baby girl is here, but she
states that she is feeling anxious.

Medications
ALLERGIES: Sulfa drugs, Amoxicillin, Penicillin

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 Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing
Effect Considerations
Oxytocin (Pitocin) 400mL/hr IV N/A Indication – postpartum Hypotension, hyponatremia,  Fetal maturity,
control of bleeding after increased uterine motility, presentation,
expulsion of the placenta painful contractions, and pelvic
(Sanoski & Vallerand, 2015). hyersensitivity (Sanoski & adequacy
Therapeutic effect – Control Vallerand, 2015). should be
of postpartum bleeding. assessed prior
to
administration
of oxytocin for
induction of
labor.
 Assess
character,
frequency, and
duration of
uterine
contractions;
resting uterine
tone; and fetal
heart rate
freqeuntly
during
administration.
 Monitor
maternal BP
and pulse
freqeuntly
(Sanoski &
Vallerand,
2015).
Morphine Sulfate 2mL IV N/A Indication – for severe pain Confusion, sedation,  Assess type,
Therapeutic effect – decreases hypotension, constipation, location, and
severity of pain (Sanoski & blurred vision, urinary retention intensity of
Vallerand, 2015). (Sanoski & Vallerand, 2015). pain prior to
and 20 minutes
after following

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 IV
administration.
 Assess LOC,
BP, pulse, and
respirations
before and
periodically
during
administration.
 Assess bowel
function
routinely
(Sanoski &
Vallerand,
2015).
Ketorolac (Toradol) 30mg IV N/A Indication – short-term Drowsiness, edema, pallor,  Assess pain
management of pain in patient vasodilation, diarrhea, dry prior to and 1-
for post-op cesarean birth mouth, increased liver enzymes, 2 hours
Therapeutic use – decreases urinary frequency Monitor following
overall pain hemoglobin A1C every 3-6 administration.
months to monitor effectiveness  Evaluate liver
(Sanoski & Vallerand, 2015). function tests ,
especially AST
and ALT,
periodically in
patients
receiving
therapy.
 Use lowest
effective dose
for the shortest
amount of time
(Sanoski &
Vallerand,
2015).
Zofran 2mL IV N/A Indication – Prevention of HA, dizziness, drowsiness,  Assess patient
nausea and vomiting fatigue, constipation, diarrhea, for nausea,
Therapeutic Effect – dry mouth (Sanoski & vomiting,
decreased incidence and Vallerand, 2015). abdominal
distension, and
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 severity of nausea and vomiting bowel sounds
(Sanoski & Vallerand, 2015). prior to and
following
administration.
 May cause
transient
increase in
serum
bilirubin, AST,
and ALT
levels (Sanoski
& Vallerand,
2015).

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)
Acute pain related to patient having a cesarean birth as evidenced by the patient stating she in 6/10 pain.

1. Perform comfort 1. These measures 1. Goal was met.

Pain will experience a
significant decrease in pain.
Patient will state her pain
level has decreased from a
6/10 to a 3/10, which she
stated would be a manageable
level, by the end of my 12
hour shift.
measures to promote
relaxation, such as
massage, bathing,
repositioning, and
relaxation techniques.
2. Plan activities with
patient to provide
distraction, such as
reading, crafts,
reduce muscle tension
or spasm, redistribute
pressure on body
parts, and help patient
focus on non-pain
related subjects.
2. This helps the patient
to focus on non-pain-
related matters.
Patient was
provided with
different comfort
measures, which
ultimately helped
to reduce her pain.
2. Goal was partially
met. Since the
patient’s baby is in

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Secondary Nursing Diagnosis:
Risk for infection related to an invasive procedure.
Patient will remain free of
infection.
Patient will show no signs of
infection (i.e. fever, elevated
WBC, tenderness, etc.)
through the entirety of my 12
hour shift.
television, and visits to 3. This promotes health,
see the baby. well-being, and
3. Manipulate the increased evergy level
environment to promote important to pain relief
periods of uninterrupted (Ralph, S. S., Taylor,
rest (Ralph, S. S., C. M., & Phelps, L. L.,
Taylor, C. M., & 2017).
Phelps, L. L., 2017).
1. Assess signs of 1. Assessing for signs
infection (e.g. of infection will
elevated allow us to watch for
temperature, pulse, any acute new
WBC). findings in the
2. Take blood or patient and prevent
vaginal cultures, as the potential
indicated. infection from
3. Record hemoglobin getting worse.
and hematocrit, and 2. This allows for the
estimated blood loss determination of the
during surgical infecting organism.
procedure (Ralph, S. 3. Risk of postdelivery
S., Taylor, C. M., & infection and poor
Phelps, L. L., 2017). healing is increased
if hemoglobin levels
are low and blood
the NICU, she is
not able to see her
baby as often,
especially since she
had a caesarean
birth. Therefore,
the next shift of
nurses should
attempt to get her
more time with her
baby.
3. Goal was met. The
patient’s
environment was
manipulated in
order to promote
health and well-
being.
1. Goal was met. The
patient was
freqeuntly assessed
for any signs and
symptoms of
infection and none
were present.
Continue to assess
throughout stay.
2. Goal was not met.
Patient did not have
any blood cultures
during my shift. This
will be passed onto
the next upcoming
nurse.
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 loss is excessive 3. Goal was met.
(Ralph, S. S., Taylor, Patient’s
C. M., & Phelps, L. L., hemoglobin,
2017). hematocrit, and
estimated blood loss
were recorded and
were all within
normal ranges.
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

Ralph, S. S., & Taylor, C. M. (2017). Nursing diagnosis reference manual. Philadelphia: Wolters Kluwer Health/Lippincott Williams

& Wilkins.

Vallerand, A. H, & Synoski, C. A. (2017). Davis’s drug guide for nurses 15th edition. F.A. Davis Company

Wilson, D., Hockenberry, M., Perry, S., Alden, K., Lowdermilk, D., C, M. C. Maternal Child Nursing Care. [Pageburstls]. Retrieved

from https://pageburstls.elsevier.com/#/books/9780323549387/