NURS 316L Nursing Care Plan PDF

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Course: NURS 316L NURSING CARE PLAN TEMPLATE NURS 316L

Student Instructor Patient Initial Code Status Allergies Temp (C/F Site) 97.8F Temporal

Krystal Dewey Karie Herber Unit/ PP, 5 Room# FULL CODE

KM NKA Pulse (Site) 78 right index finger

Respiration 20

History of Present Illness including Admission Diagnosis & Chief Complaint (normal & abnormal) supported with evidence based citations

Chief Complaint (if possible, use patient’s words): “Well I just had a CSection yesterday, so I guess my number one complaint is pain at my incision” HPI (PQRST of chief complaint, along with other pertinent pregnant complications [if any]): __31_ y.o. at 38+2___ weeks gestation, arrives to the hospital with prior noted chief complaint. Pt was admitted to L&D on 12/5/18 for a scheduled repeat cesarean section. Pt had placenta previa with first pregnancy and had a planned cesarean section at 38weeks in 2016. In this pregnancy, Pt had placenta previa which resolved to low-lying placenta without hemorrhage at 11/20 ultrasound. Repeat cesarean was scheduled for 38+2 to mitigate risk of hemorrhage. Admit Dx: Pt was admitted to L&D on 12/5/18 for a scheduled repeat cesarean section

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Date Course

12/6/18 NURS316-LA 31 years old

DOB Height/Weight Final EDC/Current Gestational Age: Pulse Ox (O2 Sat) 98% right index finger

5’7” 205lb 38+2

Blood Pressure 98/55 left upper arm

Pain Scale 1-10 2/10

Physical Assessment Findings including presenting signs and symptoms supported with Evidence Based Citations. If on postpartum, BUBBLE-HE for maternal assessment and if on antepartum/intrapartum, the following apply: fundal height, CV/Thorax, perineum, SVE, and fetal heart rate Category. 12/6/18 0800 Pt was A&Ox4. Pt had eaten 75% of her breakfast and was awaiting removal of her indwelling catheter. Pt was in good spirits and asked for her infant to breastfeed. After breastfeeding, Pt requested assistance with belly-binding and ambulated around the PP department. Pt BP at 0800 was 98/55. Low blood pressure is common after a cesarean section due to the anesthesia and pain medications. *Pt should be monitored for falls/orthostatic hypotension upon standing and assisted to the bathroom and when ambulating. Pt temperature of 97.8 does not indicate infection Pulse is WNL O2 WNL Pt reported 2/10 on the pain scale at the incision site (was given nonopioid pain medication at 0900). Pt is using incentive spirometer every 2 hours and coughing. Pt reports pain in shoulder, educated on referred pain from surgical gas, advised to ambulate to relieve gas. Pt lung sounds are clear bilaterally Dressing on incision was clean with no drainage. Edges were approximated with no redness, edema, or warmth. Dressing was

Course: NURS 316L NURSING CARE PLAN TEMPLATE NURS 316L

removed and replaced with new dressing at 0830. B(breasts): Pt breasts are firm and engorged, pt is producing colostrum and is already breastfeeding her infant. There is no redness, warmth, or tenderness apart from that caused by engorgement. U(uterus): Pt uterus is firm and midline, fundus located 1cm below umbilicus which is expected at 24 hours post partum (Durham and chapman, 2014). B(bladder): Unable to palpate bladder. Pt indwelling catheter removed 12/6/18 at 1000, Pt reported no pain upon removal or during first void. Pt’s first void after removal was 200mL at 1130, and second void was 400mL at 1345. B(bowel): Bowel sounds auscultated in all 4 quadrants. Pt was on regular diet and completed 75% of her breakfast. Pt reported a bowel movement at 1130 on 12/6/18 and noted that the stool was formed with no blood, mucus, or pain. L(lochia): Pt had light lochia rubra on pad 24 hours post partum. Pt had 1 small clot (dime sized) when she voided. Pt did not report foul odor and noted she had not experienced a gush when she stood since they day of delivery. E(episiotomy/incision): Abdominal incision (lower transverse) is clean, intact, approximated, and free of redness, edema, ecchymosis, and drainage. Incision was closed using internal dissolving stiches and glue externally. H(Homan’s sign for DVT): No redness, pain, or warmth in calves. Many facilities are no longer using the Homan’s Sign for diagnosis of DVT: “Elicitation of the Homan’s sign involves forced dorsiflexion of the respective ankle in the suspected limb. However, the sign is not very reliable and often non-invasive diagnostic modalities are necessary to confirm the diagnosis of DVT. Such modalities include ultrasonography and venography of the affected limb. The utility and use of the Homan’s sign has gradually waned down over the course of time” (Ambesh, 2017). E(edema): bilateral edema +1 in both feet R(Rubella, Rh): Pt has positive titer for rubella from previous MMR immunizations. Pt had Rh negative blood type and did not require rhogam.

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Course: NURS 316L NURSING CARE PLAN TEMPLATE NURS 316L

Relevant Diagnostic Procedures/ Results & Pertinent Lab tests/

Past Medical and Surgical History,

Values (with normal ranges), include dates and rationales supported

Pathophysiology of Medical Diagnoses

with Evidence Based Citations

(include dates, if not found state so) Supported with Evidence Based Citations

Pertinent Labs Current CBC: (12/5/18 0530) RBC 3.24L NR: 4.2-5.4 WBC 10.4 NR: 4.0-11.0 HgB 10.0L NR: 12.0-15.5 HcT 29.3L NR: 37-48 Platelet 202 NR: 150,000-450,000 GBS: Negative @ 36wk Vaginal and rectal swab cultures are done at 35-37wks gestation to determine the presence of Group B Streptococcus bacterial colonization before the onset of labor in order to anticipate intrapartum antibiotic treatment needs. (Durham & Chapman, 2014). “Group B streptococcus (strep) is a common bacterium often carried in your intestines or lower genital tract. Group B strep is usually harmless in adults. In newborns, however, it can cause a serious illness known as group B strep disease” (Group B Strep, 2018).

Prenatal Panel: @ 20wk Blood Type: ABGestational Diabetes Screen: Negative The American Association of Obstetricians and Gynecologists recommends routine screening for all pregnant women at 2428 weeks of gestation, with a non-fasting 1-hour 5-g oral glucose tolerance test. A positive test is a result of 130mg/dL or 140mg/dL depending on the criteria used (Durham & Chapman, 2014). Varicella: Positive titer Page 3 of 13

Medical Hx: Hypothyroid: Hypothyroidism is when the patient’s thyroid underproduces necessary hormones. There are further complications in pregnancy. Their medication dosages may need to be adjusted, and depending on the severity of their disease, they may require close monitoring. It is important for the OB-GYN to work in conjunction with the patient’s endocrinologist. “Treatment with sufficient amounts of thyroid hormone replacement significantly reduces the risk for developing pregnancy complications associated with hypothyroidism, such as premature birth, preeclampsia, miscarriage, postpartum hemorrhage, anemia and abruptio placentae” (The Thyroid and Pregnancy, n.d.). Atypical nevus Obesity (35-39.9) Pt current BMI 39: The World Health Organization characterizes obesity as having a BMI of 30 or greater. “Maternal obesity is a well established risk factor for developing gestational diabetes, preeclampsia, and thrombosis” (Durham and Chapman, 2014). In this case, obesity can also lead to post-surgical complications, such as slow wound healing, wound infection, excessive blood loss, DVT, and endometritis. (Durham and Chapman). OB Hx: Abnormal cervical PAP: A Pap smear is a cervical exam where the physician will swab the cervix to collect cells for testing. An abnormal result doesn’t necessarily mean cervical cancer; there are many reasons why the results would appear abnormal. “An abnormal result means some cervical cells have changed. But it doesn’t mean

Course: NURS 316L NURSING CARE PLAN TEMPLATE NURS 316L

MMR: Positive titer STI: Negative HIV: Negative Hep A,B,C: Negative PIH panel (if applicable): n/a Relevant Diagnostic Procedures Ultrasound (latest): U/S 11/20/18 to check status of placenta previa. Resolved to low lying placenta.

you have cancer. In fact, most women who have an abnormal result do not have cervical cancer. Some other reasons for an abnormal result are inflammation, infection, STI, or sexual intercourse” (Mena, 2016). Placenta Previa: in her first pregnancy, KS was diagnosed with placenta previa. “Placenta previa occurs when the placenta attaches to the lower uterine segment of the uterus, near or over the internal cervical os instead of in the body or fundus of the uterus. The cause is unknown. Hemorrhage is especially likely to occur during the third trimester with development of the lower uterine segment, and when uterine contractions dilate the cervix, thereby applying shearing forces to the placental attachment to the lower vaginal segment, or when separation is provoked by vaginal examination” (Durham & Chapman, 2014). Because of the risk of hemorrhage, KM underwent a cesarean birth at 38wk gestation. Due to this history, this present pregnancy was scheduled to have a planned repeat cesarean section with no TOLAC attempted. Low-lying placenta w/o hemorrhage: In this present pregnancy, KM was again diagnosed with placenta previa like in her first pregnancy, but an ultrasound on 11/20/18 showed a resolution to a low-lying placenta, with no hemorrhage or spotting reported. “In total, 1220 of 1240 low-lying placentas (98.4%) that had sonographic follow up resolved to no previa before delivery; 89.9% of placentas cleared the cervix by 32 weeks, and 95.9% cleared by 36 weeks. Twenty patients (1.6%) had persistent sonographic placenta previa or a lowlying placenta at or near term, including 5 complete previas, 7 marginal previas, 5 low-lying placentas, and 3 vasa previas; all had cesarean deliveries” (Heller, 2014) Surgical Hx: Previous C-Section 2016: Due to aforementioned placenta previa Family Hx: Not provided

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Course: NURS 316L NURSING CARE PLAN TEMPLATE NURS 316L

Erikson’s Developmental Stage (with Rationale). Provide examples of

Socioeconomic/ Cultural/ Spiritual Orientation

how client meets/doesn’t meet chosen stage (supported by Evidence

& Psychosocial Considerations/ Concerns (3) supported with

Based Citations).

Evidence Based Citations Socioeconomic: KM and her husband run a small business; he is a electrician and she does all of the administrative duties for the business as well as maintaining their home and taking care of their toddler, and now their newborn as well. They own their home in the city of Riverside and each has their own vehicle. Cultural: KM is a white woman, she jokingly called herself a ‘mutt’, but her husband is Romanian. Her in-laws live nearby, and plan to help her as much as possible. “Romanian families place a high value on children; their protection and well-being are considered to be parents' primary responsibilities. Considerable efforts are made to provide children with what they need. Parents' hope and pride are focused on children's successes” (Rowan and Simmons, n.d.). KM says she prefers to be independent and finds it hard to depend on others.

At the age of 31, KM would fall into the 6th developmental stage as defined by Erikson. This stage is called “Intimacy vs. Isolation”, and covers an age range of approximately 18 through 40 years. Simply Psychology explains this stage: “During this period, the major conflict centers on forming intimate, loving relationships with other people. During this period, we begin to share ourselves more intimately with others. We explore relationships leading toward longer-term commitments with someone other than a family member. Successful completion of this stage can result in happy relationships and a sense of commitment, safety, and care within a relationship. Avoiding intimacy, fearing commitment and relationships can lead to isolation, loneliness, and sometimes depression. Success in this stage will lead to the virtue of love” (McLeod, 2018). KM is demonstrating success in this stage of psychological development. KM has been married to her husband and father of her children for almost ten years and said their relationship is happy and supportive. The length of time and intimacy of the relationship demonstrates commitment, safety, and care, as outlined by McLeod above. Within the relationship, they coparent their child(ren), run a successful small business, and interact with their extended families together, while still nurturing their young nuclear family.

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Spiritual: KM identifies as Christian and attends church on Sundays. She goes with her husband and daughter to the home church of her inlaws. Her 2 year old daughter was christened in the church and she plans on christening her new baby as well. Three psychosocial concerns, based on above assessments: 1. Marital conflict: due to the stressors on KM from running their home business, parenting a newborn and a toddler, well-meaning grandparents offering support, and recovering from surgery, the marital relationship between KM and her husband may become stressed and lead to conflict

Course: NURS 316L NURSING CARE PLAN TEMPLATE NURS 316L

Erikson’s Developmental Stage (with Rationale). Provide examples of

Socioeconomic/ Cultural/ Spiritual Orientation

how client meets/doesn’t meet chosen stage (supported by Evidence

& Psychosocial Considerations/ Concerns (3) supported with

Based Citations).

Evidence Based Citations (Moses, 2018). 2. Sibling jealousy/attention-seeking: An older sibling “may react to the addition of a new family member by testing (parents) or regressing, hurting the baby, or acting out” (Helping Your 2-Year Old…, 2016). 3. Personal religious conflict: KM is dedicated to her church, but expressed concern at her inlaws’ desire to assist her when she feels independent. She may feel conflicted due to religious pressure to respect her in-laws, as well as internal pressures from motherhood and marriage. “‘Honoring’ one's parents (Exodus 20:12) does require showing them patience, kindness, gentleness, and respect. This applies to in-laws, too. You may not even like them, but you need to choose to act in a loving manner toward them If you feel your in-laws are intruding into your married life, the old saying, "Good fences make good neighbors," may apply. In concert with your mate, set reasonable boundaries; ask that he or she firmly and kindly insist that your in-laws respect these limits.” (Swiheart, 2006).

Potential Health Deviations: aka Risk Diagnoses (AT LEAST TWO) Include THREE independent nursing interventions for each (RISK FOR XXX, AS EVIDENCED BY XXX)

Risk for infection as evidenced by cesarean incision on lower abdomen 1. Monitor Pt for signs of infection to include: redness, warmth, swelling, discharge at incision site, elevated temperature over 100.4F, dizziness, pain 2. Educate Pt on signs of infection and have Pt repeat them back 3. Provide incision care using proper precautions and clean technique as needed 4. Educate Pt on incision care at home to include: changing dressings when soiled, keeping incision clean, using hand hygiene, no baths or submersion until incision is fully healed. Page 6 of 13

Inter-professional Consults, Discharge Referrals, & Current Orders (include diet, test, and treatments) with Rationale Supported with Evidence Based Citations Lactation consultant: In this hospital, the lactation consultant visits each new mother to assess her level of knowledge and skill, and will intervene or offer further education if necessary. “Lactation consultants are professional breastfeeding specialists trained to teach mothers how to feed their baby. They help women experiencing breastfeeding problems, such as latching difficulties, painful nursing, and low milk production. A lactation consultant also helps babies who aren't gaining enough weight” (What is a Lactation Consultant?, n.d.) Nutritionist: Since the patient has a BMI of 39 postpartum, which is in the obesity range, and had a BMI of 35 before her pregnancy, she requires intervention in order to assess her knowledge of nutrition and her ability to provide herself and her family with nutrient-rich healthy meals and well as

Course: NURS 316L NURSING CARE PLAN TEMPLATE NURS 316L

Erikson’s Developmental Stage (with Rationale). Provide examples of

Socioeconomic/ Cultural/ Spiritual Orientation

how client meets/doesn’t meet chosen stage (supported by Evidence

& Psychosocial Considerations/ Concerns (3) supported with

Based Citations). Risk for falls related to orthostatic hypotension due to patient’s pain medication and prior anesthesia 1. Implement fall precautions including bed rails and nurse call light 2. Ensure tidy environment in Pt room with no trip hazards such as cords, furniture, personal items 3. Ensure Pt has all needed items within reach to lessen strain or long reach 4. Assist Pt when ambulating

Priority Nursing Diagnosis (at least 2) Written in three-part statement *Risk Diagnoses NEVER go in this section. Anxiety related to parenting and childcare as evidenced by patient verbalizing uncertainty at caring for a toddler and baby alone while recovering from surgery

Planning (outcome/goal) Measureable goal during your shift (at least 1 per Nursing Diagnosis) *Think SMART GOAL*

Evidence Based Citations implement a possible exercise regimen when she has healed from childbirth.

Prioritized Independent and collaborative nursing interventions; include further assessment, Intervention and teaching (at least 4 per goal)

The patient will relate an increase in psychological and physiologic comfort.

1. acknowledge patient’s feelings of apprehension

The patient will verbalize her own anxiety and coping patterns.

2. Assess patient’s methods of coping 3. Contact hospital social worker to interview patient and assess mental

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Rationale Each must be supported with Evidence Based Citations

Having a new baby is a stressful time, and the stress is increased with each child. Thoughts on how to care for a toddler and a new baby in addition to the other duties of a family can cause apprehension and anxiety for the new mother. “Approximately 6% of

Evaluation Goal Met, Partially Met, or Not Met & Explanation

Goal partially met. Pt was able to verbalize her fears to her husband who then worked with her to create a plan for their return home. With family nearby, they were able to create a schedule for the grandparents and some friends to assist the Pt with

Course: NURS 316L NURSING CARE PLAN TEMPLATE NURS 316L

health status 4. Make plan with patient, partner, and family to assist with childcare, chores/errands, emotional support

Knowledge deficit related to lack of information as evidenced by patient stating they did not know the reason for the referred shoulder pain post-surgery or reasons to ambulate (Carpenito, 2017)

Pt verbalizes understanding of importance of ambulation Pt displays readiness to ambulate Pt will report decreased referred gas pain after ambulation

1. Give accurate information in easy-tounderstand terms and clarify misconceptions. 2. Encourage Pt to ask questions and verbalize their understanding on the matter. 3. Assist Pt in ambulation including sitting up at edge of bed to mitigate orthostatic hypotension and fall risk

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pregnant women and 10% of postpartum women develop anxiety. Sometimes they experience anxiety alone, and sometimes they experience it in addition to depression… Postpartum and antepartum anxiety are tem...