OB Care Plan

Student: Evelina Balzhyk Date: 02.25.2020

Course: NSG 432 CC Instructor: Professor Schnieder

Clincial Site: St. Joseph’s Medical Hospital and Medical Center Client Identifier: YM Age: 23

Reason for Admission:

Patient admitted herself on 02.23.2020 to have a vaginal delivery. Gestational age of her baby was 39 weeks and 6 days. YM gave birth to her
baby girl 30 hours ago.

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

YM had a normal labor and delivery and did not not have complications The patient may come into the hospital during labor or when her
associated. membranes have been ruptured (water broke). YM came into the
hospital after her spontaeous rupture of membranes. Other patients
Pathophysiology: a spontaneous vaginal delivery happens on its own,
come in when they feel strong and regular contractions, when they
without the intervening of the physician to pull the baby out. Labor
pass the mucous plug, or when they see changes in their vaginal
happens in three stages. The first stage begins with contraction, where the
discharge, these are signs and symptoms that labor is coming or is
cervix dilates to about four inches wide (“Childbirth”, 2020). The second
already active.
stage is the active stage, this is where the patient must push to move her
baby down to her canal until it is born. And the third stage involves
delivering the placenta. Within the hour after borth of the baby,
contractions are still present and the mother pushes out the placenta
(“Childbirth”, 2020).
Risk factors: there are no risk factors that could cause vaginal delivery,
but there are complications that could occur during or before the process.
Some examples are gestational diabetes, preterm labor, preeclampsia, and
infections.

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

 Assessment Data

Subjective Data: The patient says that she “feels good” after her delivery and had mild pain of 2/10 wihtin the first 12 hours after delvering her
baby.
VS #1 Labs: Diagnostics:
T : 36.5 C WBC (4.5-11): 16.8, this is high for YM. During Diagnostics were not noted, none were available.
labor, it is common for WBC cuont to increase,
BP: 135/78
so this is okay in YM’s condition; the WBC
HR: 77 bpm count should return to normal within a week
postpartum.
RR: 16 bpm
O2 Sat: YM’s O2 Sat was not Hct (37%-48%): 28.9, this is low. A low level
taken of hematocrit could be casused by anemia. YM
has a past history of anemia.
Pain: 2/10 on a pain scale of
0/10
VS #2 (Lewis, S. L., Bucher, L., Heitkemper, M. M., &
Harding, M., 2017).
T: 36.6 C
BP: 130/80
HR: 75 bpm
RR: 16 bpm
O2 Sat: YM’s O2 sat was not
taken
Pain scale: 0/10 on a pain scale
of 0/10

Assessment: Orders:

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Neuro: patient is alert and oriented x4. Communication is appropriate,  lactation consultant
patient is cooperative.  ambulation
Cardiac: Normal S1 and S2 sounds. No edeman is present in lower  monitor pain if present
extremities bilaterally. Capilarry refill is less than 2 seconds.  monitor for vaginal drainage and possible bleeding
 discharge teaching
Respiratory: Lung sounds are present and clear in all lobes bilaterally.
GI: Bowel sounds are present. Abdomen is soft.
GU: patient voids appropriately. Had BM in the morning.
Patient delivered/post partum: YM had a vaginal delivery, she gave
birth on 02.24.2020 at 0245. The baby is a female and the EBL is 350
ml.
BUBBLE HE assessment
Breast: soft, nipples intact, tender
Uterus: Firm at umbilicus, midline, fundus is at the umbilicus.
Bowel: Patient’s last BM was this morning, she is passing flatus.
Bladder: patient is voiding without difficulty.
Lochia: bleeding is scant, color is dark red
Episiotomy/laceration: patient did not have a c section
Homans sign: we no longer measure Homans sign.
Emotions: YM scored a 0 on the Slinburgh scale (test for postpartum
depression), she is cheerful but a little anxious because this is her first
child. YM communicates well.
Medications
ALLERGIES: Sulfonamides
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 Name Dose Route Frequency Indication/Therapeuti Adverse Effects & Nursing
c Effect Side Effects Considerations

Ibuporfen 600 mg PO Q6h PRN- This medication works Some adverse effects which are The nurse should
(Motrin) pain by inhibiting important to be aware of are assess pain (note
prostaglandin synthesis Stevens-Johnson Syndrome, type, location, and
and treats mild to rashes, bleeding, and intensity) prior to
moderate pain. The constipation. Side effects to and 1– 2 hr
patient was haivng pain educate the patient about include following
2/10 after delivery. headache, dizziness, drowsiness, administration.
and blurred vision.
Ferrous 325 mg PO qDay This medication is given Some adverse effects to be aware The nurse should
sulfate for the patient in order of are constipation, GI bleeding, assess nutritional
to prevent iron and vomiting. Side effect to tell status and provide
deficiency anemia. the patient about are dark stolls, patient teaching
dizziness, headache, and about the
syncope. importance of iron,
especially in
regards to the baby.
Docusate 100 mg PO BID YM is given this Adverse effects include throat The nurse should
medication to prevent irritation and rashes. Side effects assess presence of
constipation, to avoid include mild cramps and bowel sounds,
straining after delivery. diarrhea. abdominal
distention, and
usual pattern of
bowel function.
Multivitamin 1 tab PO qDat Ym takes the Adverse effects are extrememly The nurse should
multivitamin to prevent rare in recommended doses. be assessing for
any vtamin deficiencies Urine discoloration is a nutritional

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 during pregnancy and possibility. deficiency before
after delivery of her and throughout
baby. therapy.
(Vallerand, A. H., (Vallerand, A. H., Sanoski, C. A., (Vallerand, A. H.,
Sanoski, C. A., & & Deglin, J. H., 2017). Sanoski, C. A., &
Deglin, J. H., 2017). Deglin, J. H.,
2017).

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 Was goal met? Revise
reasonable, and attainable. interventions. intervention is the plan of care
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)
Ineffective feeding related to poor infant sucking as evidenced by infant crying within one hour after breastfeeding.
This was chosen as the priority diagnosis because the patient states that she has been feeding for 45 minutes when the infant starts crying,
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however, the infant is still fussy after the feedings and does not seem to be content.
Infant will show an
adequate intake during
breastfeeding
1. Assess the infant’s
Infant will show an sucking pattern during
adequate intake during breastfeeding
breastfeeding by the time 2. Teach parents the correct
of discharge and the positioning during feeding
mother’s self-esteem will the infant
increase. 3. Make referrals to
neonatal nutritionists and
lactation specialists if
necessary
(Ralph, S. S., Taylor, C. M.,
& Phelps, L. L., 2017).
1. Assessing will help
determine presence of
ineffective feeding pattern.
2. Teaching will promote
correct feeding procedure
and prevent newborn from
aspiration.
3. referrals will prevent
problems of malnutrition if
there is suspected
ineffective breastfeeding.
(Ralph, S. S., Taylor, C.
M., & Phelps, L. L., 2017).
The goal was met; the
infant showed adequate
intake of breastmilk
while feeding, by the
time of discharge. The
infant’s sucking pattern
was assessed during
breastfeeding, the
parents were taught
correct positioning
during feeding of the
infant, and a referral
with a lactation
consultant was made.

Secondary Nursing Diagnosis:

Risk for deficient knowledge related to lack of exposure.
This was chosen as a secondary diagnosis due to patient stating the presence of anxiety because this is her first experience of a delivery.

Explains how to
incorporate new regimen
into lifestyle
Explains how to
incorporate new regimen
into lifestyle by the time of
discharge.
1. Observe client's ability
and readiness to learn
(e.g., mental acuity, ability
to see or hear, no existing
pain, emotional readiness,
absence of language or
cultural barriers).
2. Determine client's
1. Education in self-care
must take into account
physical, sensory,
mobility, sexual, and
psychosocial changes
related to age.
2. New information is
assimilated into previous
The goal was met, YM
explained how to
incorporate having a baby
into her lifestyle by the
time of her discharge. YM
was observed for readiness
to learn, her previous
knowledge was
determined, and she was
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 previous knowledge of or
skills related to his or her
diagnosis and the
influence on willingness to
learn.
3. Use visual aids such as
diagrams, pictures,
videotapes, audiotapes,
and interactive Internet
web sites
(Ralph, S. S., Taylor, C.
M., & Phelps, L. L.,
2017).
assumptions and facts and provided with the use of
may involve negotiating, diagrams and videos to
transforming, or stalling. help her understand the
3. Verbal reinforcement material.
of personalized, written
instructions appears to be
the best tested
intervention. Computer-
generated, personalized
instructions improved
adherence when compared
with handwritten
instructions.
(Ralph, S. S., Taylor, C.
M., & Phelps, L. L.,
2017).

References
Childbirth | Stages of Labor | Effacement. (2020, February 6). Retrieved from https://medlineplus.gov/childbirth.html

Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. (2017). Medical-Surgical Nursing: Assessment and Management of

Clinical Problems (10th ed.). St. Louis, MO: Elsevier.

Ralph, S. S., Taylor, C. M., & Phelps, L. L. (2017). Nursing diagnosis reference manual. (10th ed.). Philadelphia: Wolters Kluwer

Health/Lippincott Williams & Wilkins.

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Vallerand, A. H., Sanoski, C. A., & Deglin, J. H. (2017). Davis's Drug Guide for Nurses (15th ed.). St. Louis, MO: Elsevier