Intrapartum Nursing Care Plan Assignment

FITSUM DERESA 1 Postpartum Nursing Care Plan Nurs-381 Prof. Akintunde Bowie State University April 10, 2019 FITSUM DERESA 2 BOWIE STATE UNIVERSITY NURS 381 PRENATAL/INTRAPARTAL/POSTPARTAL/ CARE PLAN FORMAT INTRODUCTION: Provide a brief introduction of your patient to include initials, age, blood type, PNC, GBS status, GTPAL, gestational weeks, decelerations, membrane rupture, labor induced or augmented, type of delivery- vaginal/cesarean. If cesarean, state the reason and type of incision, previous or intended contraceptive method, race, allergies, code status, past surgical history, reason for admission, fetal presentation and position, pre-pregnancy and total weight gain. Mrs. O.J is a 23-year-old African American woman who was admitted on 4/10/2019 at 1500 for worsening symptoms of preeclampsia. She is gravida 1, para 0 at 36 weeks gestation; has blood type O+. She currently weighs 110kg and has gained 3 pounds in one week. She has no known allergies. Pt is on room air, full code and no past surgical history. Presenting symptoms include epigastric pain and frontal headache rated 8/10 and 5/10 consecutively at pain scale of 0-10. Nausea and visual changes and blurred vision. +2 dependent edema, facial puffiness, chest tightness. Hyperactive deep tendon reflex graded to +4 and pt. shows sign of clonus. Elevated BP 171/103 mmHg, and pulse: 113b/minute, respiration: 22, and decreased Oxygen saturation of SPO2: 85%, temperature: 99◦F. She has tested negative for GBS, HIV, Gonorrhea, Chlamydia, Syphilis, Herpes and Hepatitis A, B and C. She does not smoke and has no history of alcohol consumption or substance use. The fetus is doing well and is active but there is a possibility of premature rupture of membranes. Vertex fetal presentation at -3 station, and the amniotic fluid was intact. No signs of fetal distress. fetal heart FITSUM DERESA 3 rate is within normal range of 154b/minute and fetal movement is felt. The cervix is 0% effaced and 0cm dilated. Perineum is intact, no blood or lochia on bed or bed pad. ASSESSMENT Integrate lab data, GYN, medical, and social histories where applicable notably: Hypertension, Diabetes, Heart Disease, COPD, smoking, alcohol, and substance abuse, etc. Note both physiological and psychological problems. Date of Patient Care: 4/10/2019 Vital Signs: BP: 171/103 mmHg, pulse: 113, respiration: 22, Temperature: 99◦F oral, SPO2: 85%, Epigastric pain level: 8 on a 0-10 scale. Intrapartum Nursing Care Plan Assignment

Headache pain level:7 on a 0-10 scale Problems in NANDA format: Stem & Etiology. Identify ALL applicable problems in each system Acute pain related to sensory disturbance as evidenced by the clients complaining of epigastric pain of 8 on a 010 scale. Neurological: Acute pain related to decreased blood perfusion to the Alert and oriented x4. Pt is oriented to person, time, place, and situation. brain as evidenced by pt complaining of frontal headache Her pupils are 6 mm, round and react to light bilaterally, corneal reflex pain of 7 on a 0-10 scale. is present, clear and effortless speech, and gag reflex is present. No history of mental disorders. Reports visual changes and blurred vision. Cardiovascular: Blood pressure of 171/103, pulse of 113, proteinuria, severe preeclampsia, no murmur or adventitious sound heard, below knee there is a moderate to severe pitting edema graded to +3, facial puffiness. -Decreased cardiac output related to increased peripheral vascular resistance secondary to hypertension as evidenced by blood pressure of 171/103. -Fluid volume deficit related to fluid shift out of vascular compartment as evidenced by edema and 3 lb weight gain in a week. FITSUM DERESA Respiratory: Respiratory rate of 22 bpm, SpO2: 85% on room air, pain in the upper section of the stomach, denied any shortness of breath, and does not smoke. Crackle is present at both bases. 4 Ineffective breathing pattern related epigastric pain and chest tightness as evidenced by RR 22 and SpO2 of 85% GI (Assess for bowl elimination and nutrition among others): Pt is PO On a regular diet, no change in appetite. Patient complains of nausea and upper stomach pain. Patient reports of epigastric pain. Pain related to sensory disturbance as evidenced by the clients complains of epigastric pain of 8 on a scale of 010. Patient may need a bedpan to meet elimination needs. GU: Amber color urine with painless urination. Bladder scan of 380ml. Protein deep stick is +4. Foley catheter was inserted for voiding. Impaired urinary elimination related to inability to initiate micturition appropriately as evidenced by clients need for catheterization. Musculoskeletal: Gait was not observed, below knee there is a moderate to severe pitting edema graded to +3. Due to her recent symptoms from severe preeclampsia, bed rest was recommended. Impaired physical mobility related to reduced range of motion as evidenced by pt being on bed rest. FITSUM DERESA 5 Integumentary Skin has normal elasticity and cool to touch, sweaty. No bruises, rashes, no sign of dehydration. No laceration, episiotomy, incision (labor didn’t take place). No vaginal hematoma or hemorrhoid. Risk for skin breakdown related to limited range of motion as evidenced by pt being on bed rest. Reproductive Pt is gravida 1 para 0. Perineum is intact. Uterus tone is moderate b/n contraction. No contraction is noted. The amniotic membrane is intact. The cervix is 0% effaced and 0cm dilated. She is not breastfeeding, no evidence of blood, lochia or fluid on the bed or bed pad. Delivery has not yet occurred. The breast in non-tender and there is no palpable masses. No evidence. Spiritual Patient is a Christian. Patient stated that her spiritual belief does not prevent her from receiving any medical care deemed appropriate for her heath and the fetus. No evidence. Sociocultural Patient is African American woman. She is unmarried. Her mother is providing social support. The father of the baby is not present. There is no information provided about her employment history or socioeconomic status. No evidence. FITSUM DERESA 6 Psychological (Include maternal-infant bonding behavior): Pt is anxious about current health status. Pt is asking questions about the care provided. Pt complained of presenting symptoms such as nausea. Anxiety related to current health status as evidenced by pt lack of knowledge about the care, signs and symptom of preeclampsia. Developmental Patient is 23-year-old so that puts her in Ericson 6th stage of psychosocial development which is Intimacy vs Isolation. The father of the baby is not present for unknown reason. It was only the mother who is there to give support and first-time expectant mother at 23 years of age without a father is stressful so I would put her in the category of Isolation if the expectant mother is neglected. However, there is no evidence why the father is not there. No evidence. Laboratory & Diagnostic Results: If lab/diagnostic data is not available, discuss expected normal values with rationales Lab Result 04/24/18 at 0713 Normal Value Implications/rationales RPR Non-reactive Non-reactive Rapid Plasma Reagin test for the presence of syphilis. A reactive test could indicate a higher risk of preterm labor or miscarriage for mother and/or IUGR, preterm birth, stillbirth, or congenital infections for the baby. FITSUM DERESA 7 GBS Negative Negative Rubella Immune 7 IU/mL or less (Negative) Hepatitis Negative Negative HIV Negative. Negative Test for the presence of Group B streptococcal bacteria. A positive test could mean baby has the possibilities of being infected. Mothers are given antibiotics and monitored for 48 hours after delivery. . Intrapartum Nursing Care Plan Assignment

Antibody titer indicates immunity to rubella, and a negative antibody titer means the mother is not immune. If mother is infected with rubella during first trimester, baby could be born with congenital infection. Tests for presence of the Hepatitis A.B and C surface antigen which indicates artificial immunity. Lack of immunity means the mother is more vulnerable to contracting the virus which could be transmitted to the baby during birth. Tests for the presence of HIV antibodies. A positive test would indicate presence of HIV antibodies in the mother’s blood and HIV infection that can be transmitted to the baby if adherence to ART is not met. FITSUM DERESA 8 Chlamydia Negative Negative Gonorrhea Negative Negative RBC 2 (low) (3.72-5.43*10/L) This test for the presence of chlamydia bacteria. A positive test would indicate that mother is infected with chlamydia which can cause neonatal conjunctivitis in the newborn as the baby passes through the birth canal. Test for the presence of gonorrhea bacteria. A positive test would indicate that mother is infected with gonorrhea which can cause neonatal conjunctivitis in the newborn as it passes through the birth canal. Could also mean preterm birth or IUGR for the baby. Red blood cells are important delivering oxygen to the tissues and bringing CO2 back to the lung for exchange. Low RBC indicates patient’s oxygen delivery to the tissues is compromised FITSUM DERESA 9 Hemoglobin 7.4 g/dL (Low) 11.1 – 15.9 g/dL Hematocrit 28.8 % (Low) 34.0– 46.6% Platelet 136 x 10(10-34 IU/L)3 cells/dL 150-379 x 103 cells/dL BUN 32 (High) (8-23mg/dL) Indicates O2 carrying capacity. A low value could indicate that mother is hypoxic or hypoxemic. This would mean low oxygenation for the baby as well which will put the baby in distress. Indicates proportion of RBCs to blood volume. Is normally low during pregnancy due to physiological anemia. A low value indicates that mother is hypoxemic or hypoxic which can cause intrauterine growth restriction and distress to the baby during labor Indicates clotting ability. A higher than normal platelet count means that the mother is more prone to forming thrombi, which could harm the baby if mother develops a PE or if clot affects placental perfusion. A lower than normal count indicates that the mother is more prone to hemorrhage which can also harm baby due to hypo-perfusion of the placenta. This test in important because pregnant mothers are in a hypercoagulation state. To evaluate kidney function. Elevated BUN is generally FITSUM DERESA 10 Creatinine 2.6 (High) (0.8-1.4mg/dL) Albumin 3.5 (3.5-5.0g/dL) ALT 40 (High) (8-37 IU/L) AST 42 (High) (10-34 IU/L) caused by dehydration or urine flow is blocked. Elevated creatinine level indicates impaired kidney function. Pt may be diagnosed with acute kidney injury. Intrapartum Nursing Care Plan Assignment

Albumin level is used to assess patient’s liver or kidney function and it is used to detect malnutrition. Used to assess liver function that is related to liver disease or muscle damage. Used to assess liver function that is related to liver disease or muscle damage. FITSUM DERESA 11 Medications: Include ALL applicable meds: Antibiotics, Antiviral, Tocolytics, Betamethasone, Induction/Augmentation meds, Comfort/Pain Management. (Extend table as needed) Generic/Trade Name Dosing/Safe Classification Reason for Use Side Effects Promethazine 6.25mg (IVPB) Antiemetic. To prevent nausea and vomiting Sedation and confusion, Magnesium Sulfate Magnesium Sulfate Packed red blood cell 6gm/100 ml (IVPB) Anticonvulsant 20gm/500ml (continues infusion) Anticonvulsant 1 unit (350ml) Blood product To stop seizure by means of cerebral arterial vasodilation which may relieve cerebral ischemia Heart disturbance, confusion, weakness, flushing, sweating. To stop seizure by means of cerebral arterial vasodilation which may relieve cerebral ischemia. It is also used in preterm labor to relax uterine muscle and stop contraction. Heart disturbance, confusion, weakness, flushing, sweating To improve hemoglobin and hematocrit count In case of allergic reaction, Fever and shivering. FITSUM DERESA Lactated ringer 125ml/hr Labetalol 12 Isotonic IV infusion Replace electrolytes, and Pt don’t generally show side effects but hydration thus, it improve kidney in case of allergic reaction localized or function generalized hives and itching. 20mg (IVP) If SBP >170 and HR >60 Q4 PRN Antihypertensive (Betablocker) To control BP and decrease vascular resistance Analgesics Relief pain, Headache Acetaminophen 650 mg Dizziness, bradycardia, hypotension. Abdominal discomfort loss of appetite, stomach pain, PRIORITIZED DIAGNOSES: Prioritize ALL the diagnosis from the assessment above. Extend the table as needed NANDA STEM ETIOLOGY (related to) S/S (as evidenced by) Ineffective breathing pattern related to related to epigastric pain and chest tightness As evidenced by RR 22 and SpO2 of 85% Fluid volume deficit related to fluid shift out of vascular compartment. As evidenced by edema and 3 lb weight gain in a week. Decreased cardiac output related to increased peripheral vascular resistance. As evidenced by blood pressure of 171/103. FITSUM DERESA 13 Acute pain. related to sensory disturbance As evidenced by the clients complaining of epigastric pain of 8 on a 0-10 scale. Impaired urinary elimination related to inability to initiate micturition appropriately. As evidenced by clients need for catheterization. Impaired physical mobility. related to reduced range of motion As evidenced by pt. being on bed rest. Risk for skin breakdown. related to limited range of motion As evidenced by pt. being on bed rest. Anxiety related to current health status Pt lack of knowledge about the care, signs and symptom of preeclampsia Using the pattern below, develop a nursing care plan for the problem with the highest priority. Intrapartum Nursing Care Plan Assignment

NURSING DIAGNOSIS #1 Nursing Diagnosis (State fully). Ineffective breathing pattern related to epigastric pain and chest tightness as evidenced by RR 22 and low SpO2 of 85% Goal: The patient maintains an effective breathing pattern as evidenced relaxed breathing at normal rate and maintain oxygen saturation >95%. FITSUM DERESA Outcomes (3) 1. Pt respiratory rate remains with in normal limit. 14 Interventions with cited Rationales State enough Interventions for the 3 outcomes 1. Assess and document respiratory rate, rhythm and depth Q4hrs. Rationale: Respiratory rate and rhythm changes are early warning signs of respiratory distress. (Gulanick & Meyers, 2014, pg. 35). 2. Encourage to take deep breaths by using demonstration such as low inhalation, holding end inspiration for a few seconds, passive exhalation, and pursed – lip breathing; educate patient how to use incentive spirometer. Rationale: The use of these techniques promotes deep inspiration, which increases oxygenation and lung surface area. Controlled breathing techniques may also help slow respiration with patients with increased respiratory rate. (Gulanick & Meyers, 2014, pg. 35). 3. Auscultate breath sounds Rationale: listening patient lung for crackles, wheezing or diminished breath sounds to detect respiratory issues (Gulanick & Meyers, 2014, pg. 198). Evaluation Statement(s) supported with Patient’s Response (clinical data) to Interventions Patient had stable respiratory rate of 12 at the end of the shift. FITSUM DERESA 2. To have patient communicate a reduction in or absence of pain that is less than 3 on a scale of 010 by the end of the shift. 15 1.Conduct an extensive pain assessment using the appropriate tool. Rationale: pain can decrease the work of breathing and change breathing pattern. (Gulanick & Meyers, 2014, pg. 198). 2. Determine the optimal route of analgesic administration depending on the pain characteristics and condition of the pt. Rationale: each route has differing rates of onset and duration, but oral administration is often selected due to convenience and relative steady blood levels (Ackley & Ladwig et al., 2017, pg. 641). 3.Ensure that there is a rest period so that the pt. can relax and find comfort. Rationale: Fatigue and worry can exacerbate pain symptoms unable to participate with care. Encouraging the pt. to rest can therefore help to lessen Patient was asked to rate pain level on a 0-10 scale. Patent rated a pain level of 2 and is breathing without difficulty by the end of the shift on 4/12/2019. FITSUM DERESA 16 pain symptoms (Potter et al, 2013, pg. 980). 3. Patient’s oxygen saturation level return to and remain within established limits 1. Monitor pulse oximetry Patient SpO2 98% at the end of the shift. Rationale: Frequent monitoring of oxygen saturation can alert healthcare provider if there is a change in patint’s condition (Gulanick & Meyers, 2014, pg. 578). 2. Assess skin color and temperature on all extremities Rationale: a change pt’s skin color to pale, blue or ashen shows increased concentration of deoxygenated blood and that shows ineffective breathing pattern (Gulanick & Meyers, 2014, pg. 198). Intrapartum Nursing Care Plan Assignment

3.Provide supplemental oxygen therapy. Rationale: Restoring patient’s oxygen saturation to normal is crucial to increase cerebral perfusion (Gulanick & Meyers, 2014, pg. 578). FITSUM DERESA 17 . NURSING DIAGNOSIS #2 Nursing Diagnosis (State fully): Fluid volume deficit related to fluid shift out of vascular compartment as evidenced by edema and 3 lb weight gain in a week. Goal: For patient to be normovolemic by the end of the shift. Outcomes (3) 1. For the patient to attain a systolic BP greater than or to 90 mm Hg or the patient’s baseline. Interventions with cited Rationales State enough Interventions for the 3 outcomes 1.Perform a history of the patient to determine cause of fluid disturbance. Rationale: This is necessary to determine the proper interventions (Gulanick & Meyers, 2014, p. 76). Evaluation Statement(s) supported with Patient’s Response (clinical data) to Interventions An optimal systolic BP of 90 mm Hg was attained after 1 day. FITSUM DERESA 18 2.Assess the patient’s weight periodically at the same time each day ensuring that the same clothing is worn. Rationale: This facilitates accurate measurement and assessment (Gulanick & Meyers, 2014, p. 76). 3.Evaluate fluid status in relation to dietary intake. Rationale: Most fluid enters the body through consumption of food and drink. Monitoring this helps to determine whether the patient’s diet is the cause (Gulanick & Meyers, 2014, p. 76). 4.Monitor and document BP and HR. Rationale: Increase in blood volume can lead to hypertension. Monitoring BP and HR are critical for timely interventions (Gulanick & Meyers, 2014, p. 76). 2. For urine output to be greater than 30 ml/hour. 1.Assess the color and amount of urine and report if less than 30 ml/hour for 2 consecutive hours. Rationale: concentrated urine is a sign of fluid deficit (Gulanick & Meyers, 2014, p. 77). Adequate fluid balance was attained by the end of the shift as evidenced by patient received 1500 ml of LR and voided 1250ml. . FITSUM DERESA 19 2. Monitor serum electrolytes and osmolality of urine. Report if values are abnormal. Rationale: Elevated levels of blood urea nitrogen is a sign of fluid deficit (Gulanick & Meyers, 2014, p. 77). 3. Intrapartum Nursing Care Plan Assignment

Determine patient’s drink preferences such as type and hot or cold. Rationale: selecting and providing the patient’s preferred fluids can help to replace lost fluids (Gulanick & Meyers, 2014, p. 77). 3. Achieve normal skin turgor. 1.Assess skin turgor and mucous membrane for signs that dehydration is occurring. Rationale: If there is loss of interstitial fluid, this can lead to a loss of skin turgor (Gulanick & Meyers, 2014, p. 77). Normal skin turgor was achieved in 1 day. FITSUM DERESA 20 NURSING DIAGNOSIS #3 Nursing Diagnosis (State fully) Anxiety related to current health status as evidenced by pt lack of knowledge about the care, signs and symptom of preeclampsia Goal: To reduce the patient’s anxiety about the treatment of preeclampsia and the safe delivery of her baby. Outcomes (3) Interventions with cited Rationales State enough Interventions for the 3 outcomes Evaluation State … Intrapartum Nursing Care Plan Assignment