Client’s Initials S.M. Age 31 LMP July 2016 EDD 3/17/17 Marital Status Married
Gravida 6_;T 3 P 0 A 2 L 3
If applicable, describe how labor was augmented or induced: C-section (primary) baby was transverse to
breech footling.
Boy / Girl – Birth Weight: 7 lbs 10.6 oz. Length: 50.75 cm APGAR: 7/9
Significant antepartal, intrapartal, or postpartum history: Car accident at 35 weeks gestation. Pt thrown
NURSING DIANOSES
PYSICAL ASSESSMENT
(PRIORITIZE)
VITAL SIGNS
Temp 98.6 F Pulse 84 Resp 20 BP 125/68
NURSING DIANOSES
CARDIOVASCULAR
(PRIORITIZE)
Apical: Regular / Irregular Rate 84 6) Risk for imbalanced fluid
volume: Risk factors: shift in
Pulses: Radial: R +2 L+2 Pedal: R +2 L +2
blood volume, edema.
Edema: Location / degree Generalized edema of Upper and
lower extremities. Non-pitting.
Varicosities: None.
Capillary Refill: < 3 seconds.
NURSING DIANOSES
Abdomen: Soft / Firm / Distended / Tender
(PRIORITIZE)
Bowel Sounds: Normoactive / Hypo / Hyper / Nausea / Vomiting
Bowel Movement since Delivery: No
GENITOURINARY 4) Risk for altered patterns of
urinary elimination r/t effects
Urine output: 1,250 ml of clear urine via Foley catheter.
of anesthesia.
Difficulty voiding since delivery Catheter removed at 1900
pt voided without difficulty.
SLEEP / COMFORT 9)Sleep Pattern Disturbance
r/t excitement, discomfort and
Sleep pattern: Pt is not well rested r/t to responsibilities of a
environmental interruptions
mother. aeb verbal report of tiredness.
Feel rested in AM? No Naps? No
Usual methods of coping with pain/discomfort:
Pt reports “suck[ing] it up”.
NURSING DIANOSES
What could you do to facilitate her growth and
(PRIORITIZE)
development? I need to build a rapport with S.M. so
that I can identify her specific needs. As a mother of
four she already knows a great deal; however, there is
always teaching that can be done. This is her first C-
section so post-operative teaching as it pertains to a
C-section may help S.M. grow.
What are the educational needs for this mother to
care for herself, her newborn, and family?
So far S.M. needs to be educated on Toradol as it is
a part of her pain management and self-care. Additionally,
she needs to be reeducated on breast-feeding techniques
in order to care for her newborn. She may also require
education on building a larger support system so that she
does not become overwhelmed with the job of being
a homemaker.
Social Support Services (if applicable)
Done on 3/15/17
HCT 36-44% 30.5 % physiologic “normal
anemia r/t adaptation”
pregnancy (Lowdermilk, p.
344)
Hgb 12-15 g/dL 10.2 g/dL physiologic “normal
anemia r/t adaptation”
pregnancy (Lowdermilk, p.
N3731 Course Packet 9
344)
MEDICATIONS: Include all Routine and PRN medications used during Labor, Delivery and
Postpartum. Describe type, amount, pharmacological actions, times of administration, reason for
administering the drug, and nursing actions. List here and attach Medication Sheets for each med.
1. Lovenox 40 mg sub daily to prevent blood clots
2. Toradol 30 mg IV push q 6 hours for 1 day to manage pain
3. Lactated Ringers 1,000 ml 75 ml/hr continuously for 13.3 hours to hydrate
4. Oxytocin IV additive 30 U in NaCl 0.9% 500 ml (40 ml/hr) continuously to contract uterus
5. Diphenhydramine 25 mg IV push 6 hours PRN for itching
6. Ibuprofen 600 mg q 8 hours PRN for mild pain of 1-3
7. Methylergonovine 0.2 mg IM PRN for hemorrhage
8. Nubian 5 mg IV push q 4 hours PRN for moderate breakthrough pain or itching
9. Naloxone 80 mcg IV push q 2 minutes PRN for opioid reversal
10. Ondansetron 4 mg IV push q 8 hr PRN for nausea and vomiting
11. Oxycodone-acetaminophen 2 tablets oral q 4 hours PRN for severe pain of 7-10 or 1 tablet for
moderate pain of 4-6
12. Oxygen therapy 1 liter via nasal cannula PRN
REFERENCES (APA) FORMAT ONLY (Must include OB text, do not use care plan books!)
N3731 Course Packet 10