Care plans are based on individual clients.

They are designed to allow the student to critically think about each client and develop
interventions for that specific client.

 If the student is assigned to postpartum (couplet care setting) their care plan should be on the postpartum mother.
 If the student is assigned to L&D their care plan should be on the laboring mother.
 If the student is assigned to the Nursery their care plan should be on the baby.
Neonatal information may be included when appropriate in the SBAR reports.
OB Care Plan

Student: Ahsan Arca Date: 4/2/2020

Course: NSG-432CC Instructor: Professor Munoz

Clincial Site: Grand Canyon University: Virtual Client Identifier: D.G. Age: 30

Reason for Admission: Patient came in for a scheduled c-section. She is 34 weeks and 6 days pregnant and has a history of HTN, type 2
diabetes and a previous c-section.

Medical Diagnoses: (Include Pathophysiology and Risk Factors): Clinical Manifestation(s):

Type 2 diabetes: this condition occurs gradually, in which the body’s
ability to metabolize sugar is compromised. When the pancreas has been
stimulated for so long, the body eventually resists the effects of insulin.
Risk factors include being overweight, inactivity, family history, and age
(“Mayo Clinic”, 2019).
Patient presented with high blood sugar level (1hr glucose test).
Other symptoms that may be seen in other patients include
increased thirst, blurred vision, fatigue, and frequent infections
(“Mayo Clinic”, 2019).

Assessment Data

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

Subjective Data:
The patient came to the unit excited to deliver her baby. She also stated that she is slightly nervous to have another c-section, as this time she
has been diagnosed with type 2 diabetes and HTN- of which she did not have prior to her previous c-section.

Taken at 0800 Labs: Diagnostics:

VS: Labs taken on 4/2/2020 at 1300 Fetal monitor: FHTS 152.
T : 36.9 1 hr glucose test 182-high (normal <180mg/dL)
BP: 159/89 *Slightly elevated, as she has Type 2 diabetes
and may be a sign that patient has not been
HR: 64
managing the condition well (Jacobson, 2018).
RR: 16
O2 Sat: 100% on RA
RBC: 3.37- low (normal 3,800,000-
Pain: 9/10 at incision site 5,000,000/mcL).
Taken at 1100 *RBC may be slightly low as a result of blood
T : 36.8 loss (Lewis et al., 2017). Patient lost 680mL of
blood during delivery.
BP: 158/62
HR: 75
Hgb: 9.8-low (normal: 11.7-17.3 g/dL)
RR: 20
*Low Hgb is a sign of blood loss (Lewis et al., 2017),
O2 Sat: 97% on RA
Client lost some blood during her c-section.
Pain: 9/10 at incision site
Normal values reference (Lewis, Bucher,
Heitkemper, Harding, Kwong, & Roberts, 2017).

Assessment: Orders:

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PMH: HTN, Type II DM, & previous c-sesction. I&O
Neuro: Patient is A&O x 3 to patient, place, and time. She appears Accucheck
anxious about being in labor. PERRLA noted, and pupil size 4mm b/l
V/S
(bilaterally).
Fundal massage and check. Monitor for edema.
Cardiovascular: capillary refill <3 in UE (upper extremity) and LE (lower
extremity) b/l. Heart rhythm regular, NSR, S1 and S2 heard, no
murmurs/S3/S4. Slight pitting edema, 1+, on LE b/l.
Respiratory: lungs are clear in all lobes b/l. Respiration unlabored with
symmetrical expansion at 20 breaths/min. She was sitting up on her
bed at Fowler’s position.
GI: Foley inserted upon arrival on 4/2/2020. Voiding without
difficulties. 100mL of urine drained from foley bag.
GU: Bowel sounds present in all four quadrants- normoactive. Patient
has been NPO since 4/1/20 at 0800.
Prior to delivery, vaginal exam revealed that patient was 8cm dilated
and 5-6 contractions every 8 minutes. AROM was performed.
Patient delivered on 4/2/2020 at 1200 by C-section. Gender of baby
was not specified. EBL: 680mL.
Include BUBBLE HE assessment:
Breast: full, nipples intact, and tender.
Uterus: Firm, midline, 2cm below umbilicus postpartum.
Bowel: Last BM was 4/1/2020 at approximately 0900. Patient is not
passing flatus.

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Bladder: Voiding without difficulty. Output of 1000mL. Foley in place
(clean, dry and intact).
Lochia: bright red. Amount unspecified.
Episiotomy/laceration: N/A. C-section performed: incision- lower
transverse, and other description was not provided/could not be
assessed.
Homans sign: Negative.
Emotions: Patient is calm and excited. She got teary eyed when she
got to saw her baby.
Medications
ALLERGIES: NKA

Name Dose Route Frequency Indication/Therapeutic Adverse Effects & Nursing

Effect Side Effects Considerations

Metformin (Glucophage)
100mg PO BID For “management of Lactic acidosis, vomiting, “Explain to
type 2 diabetes unpleasant metallic taste patient that
mellitus” (Vallerand, (Vallerand, Sanoski, & metformin helps
Sanoski, & Delgin, 2017, Delgin, 2017). control
p.817). hyperglycemia
Common s.e. include: but does not cure
Therapeutic effect: diarrhea, nausea, and diabetes- therapy
maintenance of blood vomiting (Vallerand, is usually
glucose level by Sanoski, & Delgin, 2017, lifelong”.
decreasing intestinal p.818).

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 glucose absorption. “Administer
(Vallerand, Sanoski, & before meals to
Delgin, 2017, p.817). decrease GI
effects”.

“Encourage
patient to follow
prescribed diet,
medication, and
exercise regimen
to prevent
hyperglycemic or
hypoglycemic
episodes”
(Vallerand &
Sanoski, 2017,
p.18).

20mg IV once Used to manage HTN. Adverse effects: Assess BP & HR

Labetalol (Trandate) Decreases BP by arrthymia, bradycardia, & prior to
blocking the effects of pulmonary edema administration.
beta1 on the heart (Vallerand & Sanoski, Monitor I&Os to
(Vallerand & Sanoski, 2017). identify fluid
2017). Common s.e.: orthostatic overload. Do not
hypotension, fatigue, & give if patient is
weakness (Vallerand & showing signs of
Sanoski, 2017). uncompensated
HF (Vallerand &
Sanoski, 2017).
40mg SQ daily Used to prevent VTE Osteoporotis, Assess pt. for

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Enoxaparin (Lovenox) (Vallerand & Sanoski, thrombocytopenia, signs of bleeding.
2017). eosinophilia (Vallerand & Change injection
Therapeutic effect: Sanoski, 2017). site to prevent
potentiates Common s.e. include ecchymosis.
antithrombin effect headache, insomnia, and Monitor for
(Vallerand & Sanoski, constipation (Vallerand & hypersensitivity
2017). Sanoski, 2017). reactions.
Common s.e.
include
headache,
insomnia, and
constipation
(Vallerand &
Sanoski, 2017).
Assess pt. for
signs of bleeding.
Change injection
site to prevent
ecchymosis.
Monitor for
hypersensitivity
reactions.
1000mL IV 125mL/hr Used as a source of Adverse effects: uriticaria, Monitor patient’s
Lactated ringers hydration and hypernatremia, and acid and base
electrolyte hypervolemia (“Daily balance. Evaluate
replacement/suppleme Med”, 2017). patient for
nt. Therapeutic effect: Common s.e.: headache, electrolyte
the solution contains weakness, and nausea excess, such as
electrolytes such as (“Daily Med”, 2017). calcium (watch
sodium and chloride for depression,
(“Daily Med”, 2017). hallucination, and
hypotonia). Do
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 not aminister if
patient has
abnormal liver
function (“Daily
Med”, 2017).
Acetaminophen/oxycodone 5/325mg PO Q4h PRN Used for severe pain. Adverse effects: loss of Assess pain level
(Percocet) Works by working on conciousness, clammy before and after
the CNS to alter pain skin, and bluish lips administration.
perception (“Mayo (“Mayo Clinic”, 2020). Monitor liver
Clinic”, 2020). S.e.: chills, dizziness, and function. Teach
fever (“Mayo Clinic”, patient to rise
2020). slowly to avoid
dizziness. Assess
mother’s
breathing, as well
as the newborn
(“Mayo Clinic”,
2020).
Ketorolac (Sprix) 30mg IV Q6h Decreases pain by Adverse effects: HF, MI, Assess for rash.
“inhibiting GI bleeding. Monitor pain
prostaglandin synthesis” Common s.e.: level. Evaluate
(Vallerand & Sanoski, drowsiness, dizziness, and patient’s luver
2017). headache (Vallerand & finction, as they
Sanoski, 2017). may increase. Do
not give with
aspirin, as GI
bleed may occur
(Vallerand &
Sanoski, 2017).
Nursing Diagnoses and Plan of Care
Goal Expected Outcome Intervention(s) Rationale Evaluation

7
 Client or family focused. Measurable, time- Nursing or interprofessional Provide reason why Was goal met? Revise
specific, reasonable, and interventions. intervention is the plan of care
attainable. indicated/therapeutic. according the client’s
Provide references. response to current
plan of care.
Priority Nursing Diagnosis (including rationale for choosing this as the priority diagnosis)
Deficient knowledge r/t insufficient knowledge about self-care activities during pregnancy AEB abnormal BP and 1hr glucose test.
This was chosen as the primary diagnosis, as it can be classified as “safety needs” in Maslow’s hierarchy of needs (Friberg & Creasia, 2016).
The patient needed adequate resources in order to keep her and her baby safe, especially with her medical history; inappropriate self-care
leads to negative outcomes on health status.
The goal was met.
The client will Client will show and 1. “Negotiate realistic 1. “Unrealistic goals will 1. Upon initial contact
demonstrate demonstrate to the nurse learning goals with the frustrate the patient. with client, patient-
understanding of material 3 things she has learned patient” (Phelps, Ralph, Failure to achieve goals centered care was
taught. about health & Taylor, 2017, p.602). may reduce the applied to set
management by the end 2. “Refer the patient to patinet’s interest in realistic goals with
of shift. appropriate resource learning” (Phelps, client.
people, agencies, and Ralph, & Taylor, 2017, 2. Resources were
orgamizations” (Phelps, p.602). given and shown to
Ralph, & Taylor, 2017, 2. “To ensure client to utilize.
p.602). comprehensive care” 3. Client was
3. Review exercise routine, (Phelps, Ralph, & demonstrated an
appropriate for Taylor, 2017, p.602). exercise routine,
patient’s condition. 3. To improve her health appropriate to her
status and positively condition.
impact her well-being.

Secondary Nursing Diagnosis:

Risk for infection during the postpartum period r/t c-section incision.
The patient will not Patient’s WBC will be 1. Wash hands 1. “Handwashing is The goal was partially
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exhibit signs of infection. within normal limits, the
incision site will not be
edematous, and the site
will be clean and
approximated by the end
of shift.
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.”
“before and after the single best way met; incision site was
providing care” to avoid spreading unable to be assessed.
(Phelps, Ralph, & pathogens”, 1. Handwashing was
Taylor, 2017, minimizing her risk performed at
p.579). (Phelps, Ralph, & before and after
2. “Monitor WBC Taylor, 2017, each procedure
count, as ordered, p.579). performed on the
and priomptly 2. “A total of WBC client.
report abnormal count above 2. Lab values were
values” (Phelps, 11,000/uL assessed and WBC
Ralph, & Taylor, indicates increased was WNL.
2017, p.579). production of 3. VS were assessed
3. “After delivery, leukocytes by bone per protocol to
monitor vital signs marrow” (Phelps, monitor any
every 15minutes Ralph, & Taylor, elevated values.
for 1 hour, then 2017, p.579).
every 4 hours for 3. “Elevated
24 hours” (Phelps, temperature, pulse
Ralph, & Taylor, or respiratory
2017, p.579). rates, or blood
pressure may
indicate infection”
(Phelps, Ralph, &
Taylor, 2017,
p.579).
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 References

Daily Med. (2017). Drug label information. Retrieved from https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=d3d29c8f-

c326-4097-814a-7f4e08c67068

Friberg, E. E., & Creasia, J. L. (2016). Conceptual foundations: The bridge to professional nursing practice (6th ed.). St. Louis, MO.

Jacobson, J. (2018). Glucose screening test during pregnancy. U.S. National Library of Medicine: Medline Plus. Retrieved from

https://medlineplus.gov/ency/article/007562.htm

Lewis, S., Bucher, L., Heitkemper, M., & Harding, M. (2017). Medical-surgical nursing (10th ed.). St. Louis, MO.

Mayo Clinic. (2018). Type 2 diabetes. Retrieved from https://www.mayoclinic.org/diseases-conditions/type-2-diabetes/symptoms-

causes/syc-20351193

Mayo Clinic. (2020). Oxycodone and acetaminophen. Retrieved from https://www.mayoclinic.org/drugs-supplements/oxycodone-and-

acetaminophen-oral-route/precautions/drg-20074000

Phelps, L., Ralph, S., & Taylor, C. (2017). Sparks and Taylor's nursing diagnosis reference manual (10th ed.). Hagerstown, MD.

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Vallerand, A., & Sanoski, C. (2017). Davis’s drug guide for nurses (15th ed.). Philadelphia, PA

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