NORTH CAROLINA CENTRAL UNIVERSITY

DEPARTMENT OF NURSING

Data Base and Nursing Care Plan Student Name Amber C. Mitchell Date_____10/05/11_______________

Pathophysiology(Include Normal Physiology, identify the Physiological Alteration, identify sings and symptoms).

The client is a 26 year old AA female G1 T1 A0 L0 who presented to Wake Med on 10/05/11 at 1330 pm with severe labor pains that began 10/04/11 at 10pm. After an hour of observation, the client was confirmed of experiencing true labor and was transported into a birthing suite to prepare for labor. The clients vaginal assessment confirmed that was 2cm dilated, 50% effaced, and negative 1 station. After hours of waiting for dilation, it was determined mom needed an emergency Caesarean Effacement is the process of shortening and thinning of the cervix. True labor is defined as contractions that are regular at regular intervals, increasing in frequency, duration, and intensity, pain usually begin in lower back, radiating to the abdomen. Station refers to the ischial spines that represent the narrowest diameter through which the pelvic inlet in which the fetus must pass. The Patient had had no prior prenatal care and as a result, doctors could not determine the sex of the baby and whether or not pregnancy was post-term. Caesarean delivery is the surgical removal of the infant from the uterus through an incision made in the abdominal wall and the uterus. Size and location of

the incision vary, but abdominal and uterine incisions of choice are low and horizontal. Vertical incisions may be necessary for quicker procedures, the presence of adhesions and other complications.

Growth and Development Assessment: (Erickson Developmental Stages supported with specific objective behavior indicators)

Ego Development Outcome: (18-35) Intimacy and Solidarity vs. Isolation Basic Strengths: Affiliation and Love

In the initial stage of being an adult we seek one or more companions and love. As we try to find mutually satisfying relationships, primarily through marriage and friends, we generally also begin to start a family, though this age has been pushed back for many couples who today don't start their families until their late thirties. If negotiating this stage is successful, we can experience intimacy on a deep level. If we're not successful, isolation and distance from others may occur. And when we don't find it easy to create satisfying relationships, our world can begin to shrink as, in defense, we can feel superior to others. Our significant relationships are with marital partners and friends.

NURSING DIAGNOSIS: (Identify the nursing diagnoses for the client. ALL those determined from the data collected.)

HIGH PRIORITY: 1. Acute pain related to disruption of skin, tissue, and muscle integrity INTERMEDIATE PRIORITY: 2. Risk for infection r/t to Caesarean Delivery incision. LOW PRIORITY: 3. Risk Constipation related to insufficient physical mobility resulting in decreased gastric motility

Teaching Needs (include home care issues/needs- discharge instructions):

I.

Will teach patient to follow physicians orders on all pain medications, taking them as prescribed and as needed for pain

II.

Will encourage patient to utilize deep breathing techniques as a nonpharmacological means of pain relief; as well as guided imagery.

III. IV.

Will encourage Client to continue to eat a more balanced diet to promote healing and strength. Upon discharge, I will underscore the need for the client to adhere to the instructions for caring for her incisional wound so as to prevent the onset of infection.

REFERENCES: (ATTACH A SEPARATE PAGE IF NECESSARY USING APA FORMAT)

Ackley, B.J., & Ladwig, G.B. (2008). Nursing diagnosis handbook: An evidence-based guide to planning care (8th ed.). St. Louis: Mosby Elsevier.

Harder, Arlene F. MA,MFT(2002). Learning Place Online.com. The Developmental Stages of Erikson. Retrieved March 21, 2011, from www.learningplaceonline.com/stages/organize/Erikson.htm

PHYSICAL EXAM (Objective Data)

NORTH CAROLINA CENTRAL UNIVERSITY DEPARTMENT OF NURSING

NURSING CARE PLAN

Student: ___Amber Mitchell______________Client id initials):__Ms. M_______ Location:__Wake Med Hospital______ Date: 10/05/11

Assessment Data Nursing (pertinent to this Diagnosis/Col Nursing Diagnosis) laborative Problem Subjective

Expected Client Outcomes (GOALS) Short/Long Term Short Term After 6 hours of nursing interventions , the patient pain will be relieved or controlled. Long Term Pt pain will be successfully managed by discharge

I am in so much pain
Objective Facial mask of pain. Guarding behavior. Narrowed focus. V/S taken as follows: T: 37.3 P: 80 R: 18 Bp: 110/90

Acute pain related to disruption of skin, tissue, and muscle integrity.

Nursing Interventions/ Implementation Independent 1.Evaluate pain regularly noting characteristics, location, intensity (010 scale). 2. Identify specific activity limitations. 3.Recommend planned or progressive exercise. 4.Schedule adequate rest periods. Review importance of 5. nutritious diets and adequate fluid intake. Reposition as indicate Provide additional comfo5. Teach measures like back rub, Encourage use of relaxation 6.technique like deep breathing exercises.

Scientific Rationale 1.Provides information about need for or effectiveness of interventions. (Ackley&Ladwig, 2008) 2.Prevents undue strain on operative site. (Ackley&Ladwig, 2008) 3.Promotes return of normal function and enhances feelings of general well being. 4.Prevents fatigue and conserves energy for healing. 5.Provides elements necessary for tissue regeneration or healing.

Evaluation Short/Long Term Short Term After 6 hours of nursing intervention, the patient pain was relieved or controlled. Plan of care to continue Long Term Unable to determine not being present at discharge. Plan of care to continue

6.May relieve pain and enhance circulation. Improves circulation, reduces muscle tension Dependent Administer and anxiety associated with pain. (Ackley&Ladwig, 7. analgesics or non 2008) steroidal antiinflammatory drugs as Relieves muscle and prescribed. emotional tension.