OB Care Plan

Student: Caityn Summers Date: 06/17/20

Course: OB Instructor: Professor Gayongala

Clincial Site: Grand Canyon Hospital Client Identifier: L.S. Age: 28

Reason for Admission: Patient L.S. is a 28-year-old female patient who was admitted to the hospital for induction of labor due to preclampsia.
The GTPAL is (2, 1, 0, 0, 1) and is a gestational age 39 weeks and 2 days. Her assessment prior to delivery consisted of a vaginal exam that
showed she was 7cm/90%/-2. Her vitals were also taken and she rated her pain at a 5/10. Her labs showed several indications of pre-eclampsia,
including low RBC count, low hematocrit, low platelet, and protein in the urine. Patient is also complaining of shortness of breath, blurred
vision, and feels lethargic.

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

Pre-Eclampsia –
Pre-eclampsia is caused due to maternal and fetal/placental factors that
cause abnormalities with the development of placental vasculature early
on in the pregnancy that can lead to placental
underperfusion/hypoxia/ischemia (Karumanchi, 2019). The risk factors
that can lead to pre-eclampsia include: personal or family history of
preeclampsia, chronic hypertension, frist pregnancy, older than 35, african
american, obese, a multiple pregnancy, and having babies less than two
years apart or more than ten years (Mayo Clinic, 2020)
L.S. presented with protein in the urine, burry vision, sortness of
breath, lethagry, decreased platelet level, and low hemoglobin,
hematocrit and RBC count.
Other signs and symptoms of pre-eclampsia include severe
headaches, other vision changes such as vision loss or sensitivity to
light, nausea or vomiting, decreased urine output, and impaired
liver function (Mayo Clinic, 2020)

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

 Assessment Data

Subjective Data: “ I don’t feel good, something is wrong. I cannot get out of bed, my vision is getting blurry and it feels like I
can’tcatch my breath.”
Include TWO sets of vitals Labs: taken at 6/16/20 Diagnostics:
from your shift.
Blood type: A+ Ultrasound
VS – 6/16/20 at 0800
Antibody Screen: negative FHTS
T: 37.2 C Oral
RPR: positive
BP: 128/82 - Strip #1
Rubella: immune
HR: 110 o Baseline heart rate: 135 bpm
HIV: negative
RR: 18
1-hour glucola: 184 o Variability: minimal
O2 Sat: 99% on room air
3-hour GTT: within normal limits o Decelerations: present (2)
Pain: 5/10
Hep B: negative
o Acccelerations: absent
Chlamydia: negative
6/16/20 at 1100
GBS status: positive o Reactive
T: 37.2 C Oral
RBC 2.53 m/mm3 Low (normal 4.2 – 5.4) - Low - Strip #2:
BP: 100/50
RBC can be associated with the pregnancy
HR: 110 o Baseline heart rate: 140
Hgb 6.8 g/dL Low (normal 12.0-16.0)
RR: 20
- Low Hgb is a result of the patient having Pre- o Variabilty: absent
O2 Sat: 93% on room air eclampsia
o Decerations: late decels
Pain: 5/10 HCT 24.5% Low (normal 45.0- 48.0)
- Low HCT is a result of the patient having Pre- o Accelerations: absent

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 eclampsia o Non-reactive
Platelets 100,000 mm3 Low (normal 150,000-
- Urine protien testing
400,000)
- Low platelet count is a result of the patient
having Pre-eclampsia
ALT 30 u/L normal
AST 35 u/L normal
Uric Acid 4.0 mg/dL normal
Urine Protein to Creatinine Ration 300 mg High
(normal 150-200)
- High urine protein to creatinine ratio is a result
of the patient having Pre-eclampsia.
Magnesium Serum 12 mg/dL High (normal
range 1.7-2.2)
- High magnesium serum levels is a result of the
patient having magnesium toxicity from the
medication she is receiving

Assessment: Orders:
PMH: no past medical history Code Status
Neuro - Full Code
- A & O x 4, reflexes 2+
- PERLA Diet

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 - Clear speech - Regular
Cardiovascular Vitals Q4H
- Heart regular and rhythm with S1 and S2 present
- No S3 or S4 sounds CBC Panel
- No bruits
Continuous Infuison
- Sinus Rhythm
- radial and pedal pulses palpable 2+
- Lactated Ringers
- Cap refill less than 2 seconds, mild edema present in legs
Respiratory Magnesium Sulfate serum levels

- Lungs are clear to auscultation in all four lobes

GI
- Round with no bulges
- Bowel sounds were auscultated in all four quadrants
- Normoactive
- Last bowel movement was yesterday 6/15
GU
- Patient voids
- Clear, yellow urine, no sediment
- No distention
- Urine output: 1000mL
IV
- 20 gauge in L forearm 100mL, 125mL/hr
Sterile Vaginal exam
- 6cm; 80% effacement, -1station

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AROM
- Patient had Spontaneous rupture of membranes: Thick
meconium
Contractions
- Q 5 minutes
FHTS
- 156 bpm

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 Medications
ALLERGIES: NKA

Name Dose Route Frequency Indication/Therapeuti Adverse Effects & Nursing Considerations
c Effect Side Effects
Oxytocin 40ml/hr IV Continuous IV induction of labor at term. Maternal: Coma, seizures, - Fetal maturity, presentation, and
IV facilitation of threatened hypotension, hyponatremia, water pelvic adequacy should be
Classification abortion. IV/IM Postpartum intoxication, increase uterine motility, assessed prior.
: hormones control of bleeding after the painful contractions, abruptio - Assess Character, frequency,
expulsion of the placenta placentae and duration of uterine
(Vallerand, Deglin, Sanoski, contractions, resting uterine tone,
2017). Fraternal: Intracranial hemorrhage, and fetal HR frequently. Monitor
asphyxia, hypoxia, arrhythmias maternal BP and pulse frequently
(Vallerand, Deglin, Sanoski, 2017). and fetal HR continuously
- Monitor for signs of water
intoxication
(Vallerand, Deglin, Sanoski,
2017).
Magnesium 50ml/hr IV Continuous Preterm labor, resolution of Drowsiness, decreased RR, - Accidental overdose, have the
Sulfate eclampsia, premature rupture arrhythmias, bradycardia, hypotension, second person double-check
of membranes (Vallerand, diarrhea, muscle weakness, flushing dosage, monitor pulse, BP,
Classification Deglin, Sanoski, 2017). (Vallerand, Deglin, Sanoski, 2017). respirations, and ECG, monitor
: mineral and neuro status, seizure precautions,
electrolyte monitor newborn for hypotension,
replacements/ hyporeflexia, and respiratory
supplements distress, monitor
I&O's(Vallerand, Deglin, Sanoski,
2017).
Tylenol 1000mg PO Q6H PRN Treatment of mild to Headache, dizziness, drowsiness, - Patients who have asthma,
moderate pain, fever. intraventricular hemorrhage, aspirin-induced allergy, and nasal
Classification Inflammatory disorders and amblyopia, blurred vision, tinnitus, polyps are at increased risk of
: antipyretics dysmenorrhea (Vallerand, constipation, vomiting, dyspepsia, developing hypersensitivity
Deglin, Sanoski, 2017). nausea (Vallerand, Deglin, Sanoski, reactions.
2017). - Assess for rhinitis, asthma, and
urticaria.
- Assess for signs and symptoms
of GI bleeding.
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Lactated 1000ml IV 125 ml/hr IV: Hydration and provision
Ringers of NaCl in deficiency states.
Maintenance of fluid and
Classification electrolyte status in situations
: mineral and in which losses may be
electrolyte excessive (excess diuresis or
replacements/ severe salt restriction).
supplements Therapeutic effects: IV, PO
replacement in deficiency
states, and maintenance of
homeostasis. (Vallerand,
Sanoski, & Deglin, 2017).
Penicillin G 3 million IV Q4H Treatment of a wide variety
Potassium units/50mL of infections including
Pneumococcal pneumonia,
Classification streptococcal pharyngitis,
: syphilis, and gonorrhea
Anti-infective strains. Therapeutic effects:
bactericidal action against
susceptible bacteria.
(Vallerand, Sanoski, &
Deglin, 2017).
Nursing Diagnoses and Plan of Care
Goal Expected Outcome Intervention(s)
Client or family focused. Measurable, time-specific, Nursing or interprofessional Provide reason why
CV: pulmonary edema
F and E: hypernatremia, hypokalemia,
hypervolemia
Local:irritation at IV site.
(Vallerand, Sanoski, & Deglin, 2017).
CNS: seizures. GI: diarrhea, epigastric
distress, nausea, vomiting,
pseudomembranous colitis. GU:
interstitial nephritis. Derm: rash,
urticaria. Hemat: eosinophilia,
leukopenia. Local: pain at IM site,
phlebitis at the IV site. Misc: allergic
reactions including anaphylaxis and
serum sickness, superinfection.
(Vallerand, Sanoski, & Deglin, 2017).
Rationale
- Assess patients for skin rash
frequently during therapy.
(Vallerand, Deglin, Sanoski,
2017).
- Assess fluid balance (In taking
output, daily weight, edema, lung
sounds) throughout therapy
- Assess patient for symptoms of
hyponatremia (tachycardia,
headache, nausea, muscle cramps,
vomiting) or hypernatremia
(edema, Weight gain, fever,
tachycardia) throughout therapy
- Monitor her serum sodium,
potassium, bicarbonate, and
chloride concentrations.
(Vallerand, Sanoski, & Deglin,
2017).
- Assess for infection at the
beginning of and during therapy
- Obtain a history a determine
previous use of and reactions to
penicillins.
- Obtain specimens for culture
and sensitivity before initiating
therapy.
- Observe patients for signs and
symptoms of anaphylaxis.
(Vallerand, Sanoski, & Deglin,
2017).
Evaluation
Was goal met? Revise
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 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:
Impaired tissue perfusion related to maternal hypovolemia as evidence by changes in fetal activity and heart rate.
This was chosen as the primary nursing diagnosis due to the decline in the fetal heart tone sounds.
The patient will have no 1. Note the fetal 1. These medicatios 1. The patient was
The patient will be free of late decelerations shown response to often cause reduced assessed every 2
late decelerations. on the fetal monitor and. medications, like the fetal respiratory and hours for an
Magnesium Sulfate cardiac function signs of blood
that the patient is and fetal activity from the incision
reciving. level, even when and blood
2. Educate the mother circulation is pressure was
and family on what adequate. taken every 2
is occuring with the 2. Educating the hours.
fetus on the fetal patient and family 2. Met. The patient
monitor and allow will allow them to and family were
them to ask be involved in the successfully able
questions to clarify. care and reduce to understand the
3. Place the patient in anxiety they may be situation and ask
side-lying position, feeling any questions
place oxygen on at 3. The side-lying they wanted.
10L/min and position reduces 3. Met. The patient
increase IV fluids. pressure of the transitioned into
uterus against the side-lying
(Phelps, Ralph, & Taylor, ascending vena position, O2 was
2017). cava and placed on the
descending aorta. patient and the
The oxygen will IV fluids were
increase oxygen to increased.
the mother and (Phelps, Ralph, &
baby.
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 (Phelps, Ralph, & Taylor, Taylor, 2017).
2017).

Secondary Nursing Diagnosis: Risk for Maternal Injury related to decreased venous return as evidence by shortness of breath and
decrease O2 sat.
This was chosen as the secondary nursing diagnosis because it exhibits worsening signs of pre-eclampsia and is causing late decels in the fetus.

The patient will show Patient will report 1. Assess vitals every 1. Assessing vitals 1. Met. The nurse
improved breathing and decreased shortness of 30 mintues. more frequently assess the patients
oxygen. breath and O2 sat will be 2. Educate the patient will provide better vitals every 30
maintained above 95%. on other potential interpretation on minutes.
signs and the mother and 2. Met. The patient
symptoms of pre- fetus’s response was able to
eclampsia (such as and improvement. awknowledge that
headache, 2. Edicating the she understood the
decreased urine patient involves signs and
output and low them in the care symptoms, and
back pain) and also makes even repeated them
3. Have the patient in them more aware back.
lateral (side-lying) of what side effects 3. Met. The patient
position. to look out for that was placed in side-
may indicate the lying position to
(Phelps, Ralph, & Taylor, need for help better
2017). emergency oxygenate the
interventions. fetus.
3. This will Improve
venous return, (Phelps, Ralph, & Taylor,
cardiac output, and 2017).
renal/placental
perfusion.
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 (Phelps, Ralph, & Taylor,
2017).

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.

References

Karumanchi, Ananth, et al. “Preeclampsia: Pathogenesis .” UpToDate, Sept. 2019, www.uptodate.com/contents/preeclampsia-

pathogenesis.

Mayo Clinic. (2020). Preeclampsia. Retrieved from https://www.mayoclinic.org/diseases-conditions/preeclampsia/symptoms-

causes/syc-20355745

Phelps, L.L., Ralph, S. S., Taylor, C.M. (2017). Spark & Taylor’s nursing diagnosis reference manual (10th ed). Philadelphia, PA:

Wolters Kluwer
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Vallerand, A., Sanoski, C., & Deglin, J. (2017). Davis’s drug guide for nurses (15th ed.). Philadelphia, PA: F.A. Davis

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