N202 OB Weekly Clinical Paperwork

Student Name: O.O. Date: 6/13/20

The purpose of this assignment is to build clinical reasoning for clinical and to prepare you for NCLEX. This is due as
assigned by your clinical instructor following your clinical. Each week include one SLO and one course outcome that
you have met.

Patients Initials/room number: Age: 17

Gravida/Para: G1P1001 Weeks of Gestation: 37wks

MOTHER

Blood Type: O- Hepatitis: (-) HIV: (-) RPR: (-) Rubella status: (-) GBS: (-) Diet: NPO

Mode of Delivery: Spontaneous Vaginal Vacuum Cesarean Section

Maternal OB, medical history, surgical list: provide a brief description of each and its impact on the pregnancy:

O.O. is a pos-partum 17-year-old adolescent women. This is her first pregnancy; she has her mother here to support
her. However, the baby’s father is not in the picture. She’s had a pretty uneventful pregnancy this far, however, when
she was about 28 weeks pregnant, she was told she was rH negative. She tells the nurse that it means she’ll need two
shots to make sure she does not harm her baby, or harm babies in future pregnancies. She has attended all her
obstetric appointments with her mother by her side. Her mother seems supportive, however, understandably
frustrated because she was a teenage mother as well. O. O.’s mother voices concern about how to prevent future
teenage pregnancies—O. O. seems on board with the topic as well, because she knows that it has been a struggle—
attending school while pregnant.

Allergies, their drug classifications food allergies, and client’s reaction:

NKDA

Signs/symptoms of current problem/need (if applicable);

O. O. delivered a healthy baby girl about 24 hours ago. She’s currently complaining of 3/10 pain to her perineum after a
2nd degree tear to the posterior aspect of the vaginal opening—the doctor used dissolvable suture to repair, sutures are
intacted. O. O. has been educated on proper post suture care and has positively demonstrated the care needed. She
does note that she wishes to breast feed, however, does not feel her milk has come in yet, thus complains of cracked
and painful nipples. headache—no blurred vision, shortness of breath, altered mental status, and/or chest pain.

BABY

Birth date and time: 6/13/20 0800 Sex of baby: Female

Birth weight: 4lbs 3oz Current weight: 4lbs 0oz

Weight loss percentage: 3%

APGAR score: 6/7 Breast/Bottle: Breast

Newborn complications with pregnancy, labor, delivery: provide a brief description of each and its impact on the
pregnancy:

FHT WNL with average variability. + fetal movements.

Top 3 priorities of care (on your patient): Top 3 nursing interventions (related to priorities):

1. Emotional support as O. O. is a teen mother

 The nurse would want to communicate therapeutically and offer support.

2. Physical support as she’s coping with just giving birth, body changes, etc.

 Provide emotional support throughout hospital stay

3. Education about how to care for a newborn.

 Educate on infant safety.

Client Medications (Medications given during scheduled shift including PRN medications)

Generic/Trade Name: Is this a new medication?

Rho(D) Immune Globulin No, this is the second dose of this medication given during
pregnancy. The first dose was given at 28 weeks.
Classification:

Ther. Class.
Vaccines/immunizing agents Any pertinent teaching about this medication?

Pharm. Class. Immune
globulins
Medication order:
300mcg IM x 1 dose within
72hrs of delivery
Being that this would be the second time the patient is receiving this
medication during pregnancy. The nurse would want to re-educate
the patient on anything she has questions about
Why is this medication prescribed?
This medication is prescribed to prevent further miscarriages related
to blood incompatibility.

Is this a safe dose?

What pertinent pre- and post- assessments are necessary?
Yes
Type and crossmatch of both the mother’s blood and newborn’s cord
blood must be performed to determine the need for medication.
The mother must be Rh(d) negative. Additionally, an infant born to a
woman tested with Rh(D) immune globulin antepartum may have a
weakly positive direct Coombs test result on cord or infant blood.

What labs if any would need to be monitored and why?

Is this medication compatible with the patient's other medications?


Generic/Trade Name:
Oxytocin
Classification:
Ther. Class. hormones
Pharm. Class. Oxytocics
Medication order:
Is this a safe dose?
Yes. IV (Adults)—titrated up
every 30-60min until desired
contraction pattern is
established.
If not what are your actions or interventions?
Yes.
Is this a new medication?
Yes
Any pertinent teaching about this medication?
Advise patient to expect contractions similar to menstrual cramps
after administration has started.
Why is this medication prescribed?
Stimulates uterine smooth muscle, producing uterine contractions
similar to those in spontaneous labor. Also has a vasopressor and
antidiuretic effects. Therefore, induces labor and controlled
postpartum bleeding.
What pertinent pre- and post- assessments are necessary?
 Fetal maturity, presentation, and pelvic adequacy should be
assessed prior to administration of oxytocin for induction of
labor.
 Assess character, frequency, and duration of uterine
contractions; resting uterine tone; and fetal heart rate frequently
throughout administration. If contractions occur <2 min apart and
are >50–65 mm Hg on monitor, if they last 60–90 sec or longer, or
if a significant change in fetal heart rate develops, stop infusion
and turn patient on her left side to prevent fetal anoxia. Notify
health care professional immediately.
 Monitor maternal BP and pulse frequently and fetal heart
rate continuously throughout administration.
 This drug occasionally causes water intoxication. Monitor
patient for signs and symptoms (drowsiness, listlessness,
confusion, headache, anuria) and notify physician or other health
care professional if they occur.
What labs if any would need to be monitored and why?
Monitor maternal electrolytes. Water retention may result in
hypochloremia or hyponatremia.
Is this medication compatible with the patient's other medications?
 If not what are your actions or interventions?

Yes.

Lab NormalRange Trends (i.e. Today’s How does it relate Nursing

Yesterday, to your patient’s Intervention/Assessment/Follow up:
Value
day prior) disease process? What do you do about it?

WBC 5-10,000 9,500

Hgb 12.0-17.0 10

Hct 36-51% 35%

Platelet 140-450 145

Na 135-145 137

K 3.5-5.0 3.8

Cl 95-105 100

Mg 1.6-2.4 1.8

Ca 8.4-10.2 8.8

Phos 2.5-4.8

INR *0.8-1.1

aPTT *22-32

ABGs

pH 7.35-7.45

paO2 80-100

paCO2 35-45

HCO3 22-26

O2 93-100%

albumin 3.5-5g/dl

aLT 4-36 IU

AST 0-35units/L

Alkaline Phosphatase 30-120units/L

(ALP)
Total Bilirubin 0.3-1.0mg/dl

Other:

Diagnostic Test (Bili check, CCHD)

Date Test Type Results Significance

November, Blood type A- Rh(d) negative blood increased the
2019 possibility of blood incompatibility
with the fetus, therefore, increasing
the risk of potential
miscarriages/abortions

June 2020 Type and Cross A- (See above)

MOM Assessment findings and clinical significance.

Pain: 8/10 r/t contractions

Resp: WNL; lungs CTA

Cardiac: Heart rate/rhythm strong regular S1/S2 present; no rubs/murmurs

GI (stool, hemorrhoids, bowel sounds): LBM earlier today WNL; no hemorrhoids/anal bleeding; bowel sounds active

GU(fundus, lochia, voiding): Fundus at appropriate height r/t gestational age; mild vaginal bleeding; mild clear
amniotic fluid; last voided an hour ago—clear, odors, pale yellow urine

Breasts: WNL; minimal discharge—clear in color; no pain

Skin (perineum, C-Section site): No alteration at this time

Coping, bonding: None; O.O is still in labor

VS trends (include your 2 sets and hospitalization trends):

Vitals: MOM Temperature Pulse Respiratory Rate Blood Pressure Pulse Oximetry
Previous Shift: 98.8 67 16 122/76 98% on room air
Current: 98.0 88 20 110/68 99% on room air

BABY Assessment findings and clinical significance

Pain(NIPS): NA

Resp: NA

Cardiac: NA

GI (stool, bowel sounds): NA

GU(voiding): NA

Feedings: NA
Skin (color, rash): NA

Head: NA

Musculoskeletal: NA

VS trends (include your 2 sets and hospitalization trends):

Vitals: BABY Temperature Pulse Respiratory Rate Blood Pressure Pulse Oximetry

Previous Shift:
Current:
MOM Assessment Data Diagnosis Desired Outcomes

Objective: Problem Statement: (What will the client do?)

 Pt is three hours post Knowledge deficit due to infant  The patient will be able
birth care, as evidenced by postnatal to state lactation
 Pt verbalizes concerns state. resources offered by the
over baby’s health. hospital by the end of
the shift 6/20/20.
 The patient will be able
to identify resources
Subjective: that promote healthy
Etiology:
 Pt stars off into space coping by the end of in
The impact of adolescent patient stay.
when in the room
 Pt states “I am not sure
pregnancy on the individual has  The patient will
far-reaching consequences, verbalize increased
how to take care of the
infant.” which may restrict or limit their sense of self-esteem in
 Pt become tearful when future. Educational goals may relation to current
discussing concerns. be altered or eliminated thus, situation by the end of
limiting the potential for a the next shift 6/21/20.
productive life. The patient may
frequently be of lower
Priority: socioeconomic status this
pregnancy perpetuating
 The priority for this financial dependence and
patient is supporting her lowered self-esteem.
throughout the
postnatal period and
offering support to her
and her family. Signs and Symptoms:

 Pt stars off into space

Nursing Interventions
when in the room
 Pt states “I am not sure
how to take care of the
infant.”
 Pt become tearful when
discussing concerns.
 Pt is three hours post
birth
 Pt verbalizes concerns
over baby’s health.

Supporting Rationale Evaluation Data

(What will the nurse do?) (Reference/Source) Date:

6/20/20
 Parent education on  Nursing staff need to be
infant. able to communicate Goal 1 met, the patient was able
 Breastfeeding assistance with patient in a to state lactation resources.
o Possibly lactation therapeutic way without
consultant basis Goal 2, in progress. Pt able to
o Support the  Maternal support is of relay positive coping measures,
mother no most importance at this however, continues to struggle
 matter her time due to the risk of with accepting reality. Will
choice to feed adverse mental health reassess at the end of next shift.
infant conditions
o Inform patient  Support the mother’s Goal 3, Partially met, pt is able
that her milk choice to breast feed vs. to verbalize increased self-
may not come in bottle feeding esteem, pt was able to verbalize
for 4 days  Obtain support needed increased self-esteem, however,
 Lactation counseling to achieve the goals—in observable behaviors show
 Teaching due to this pt’s case, possibly otherwise.
individual infant lactation counseling
needs/cues  Teaching infant cues is
o Different important as an infant
cries/movements exhibits behavior that
mean different should cule the mother
things into needs (ie. Lip
 Teaching on infant smacking meaning the
nutrition infant is hungry)
o On demand  Maternal nutrition is
feeding extremely important
o Cluster feedings after child birth—first
o Feeding for healing, second to
frequencies support the infant’s Revision:
o Count number of needs to nurse,
Goals 2 & 3—Will continue
urine and BM therefore, it is essential
that the pt continues to above plan and re-assess at the
diapers
maintain a healthy diet. end of the next shift.
 Teaching on maternal
nutrition as mother is  Infant safety is
breast feeding extremely important
o Increased fluid especially to a first-time
intake mother—during the
o Slightly increase newborn phase it is
caloric intake important to discuss
 Teaching infant safety SIDS with the patient
o Care seat safety and care seat safety to
 Teach/demonstrate prevent adverse
newborn care outcomes.
o Bathing—no fully  Newborn care is
important to every
submerged bath
postnatal patient—there
until umbilical
may be new
cord stump falls
recommendations about
off
infant care
o Bathing—
 Positive reinforcement is
Cleanest areas to
extremely important for
dirtiest
an adolescent mother to
o Diaper changing
prevent negative
o Diaper rash
feelings toward self-
o Nonnutritive
and/or baby.
sucking
 Positively reinforce
mother’s knowledge set
in relation to taking care
of the baby
BABY Assessment Data Diagnosis Desired Outcomes
Objective: Problem Statement: (What will the client do?)

Etiology:

Subjective:

Signs and Symptoms:

Priority:
Nursing Interventions Supporting Rationale Evaluation Data

(What will the nurse do?) (Reference/Source) Date:

Outcome Summary:

Revision:
Medical interventions used to treat admission problem/diagnosis (Pharmacology, surgery, treatments, therapy, etc.).
How does this compare to what you read in the textbook?

The interventions which were discussed in the book are consistent with the plan of care for this patient.

Discuss client teaching provided (include client barriers to teaching, including use of blue phone/interpreter):

The biggest barrier to teaching for the client is her age and low self-esteem. These factors increase the risk of
misunderstanding information, therefore, predisposing the patient to adverse outcomes. Additionally, the patient’s
mother is there, which could both be a barrier to communication or an enhancement to communication.

After reflecting on your clinical performance today, what area’s do you feel you need to continue to work on?