Care plan and concept map

Nursing Care Plan

Kimberly Mekler, MSN, RN Keiser University

Maternal-Newborn Nursing

6/30/2021

Client Data:		Date of care: 5/25/16
Initials: AD	Age: 24	Gender: Female
Weight: 167 lb	Height: 5ft 7in	Race/Ethnicity: African American
Diet: Ice chips, progress as tolerated post-surgery. Then Gestational diabetes diet, 2000 calories.	Religion: Catholic	Room Number: Baby Suite 7
Allergies: Sulfa, cillins	Marital Status: Married	Code Status: Full Code
Past Surgeries: 2015- C-section(emergency)	Consults: None at this time	Social Habits: Goes to church every Sunday with family. Denies tobacco, ETOH, and illicit drug use.
Time	Vital Signs:
0711	B/P: 136/86	P: 87	R: 20	T: 98.6	SAO2 sat: 98% on room air
1108	132/88	87	20	98.6	97% on room air

Admitting / Primary Diagnosis: Repeat C-section

GTPAL: Prenatal: Gravida 2, Term 1, Preterm 0, Abortions 0, Living Children 1 After delivery: Gravida 2, Term 2, Preterm 0, Abortions 0, Living Children 2

Prenatal History: Pt has been seen throughout her whole pregnancy at Women’s Care of Brandon since 10 weeks. Gestational diabetes controlled by diet- no keytones or protein present in urine, GBS +

Labor and Delivery Information: Pt is a repeat C-section due to previous emergency C-section. External monitoring shows irregular contractions, mild intensity, and irregular frequency, duration approximately 50-60 sec. Fetal presentation is vertex. FHR 145 with moderate variability, with no decels noted, with accelerations. OR medications: Lactate ringer’s, spinal anesthesia was given in OR as one time dose, clindamycin, and gentamicin ran in OR for prophylaxis. Oxytocin given. Foley catheter placed. Warm blankets applied in OR. Husband at bedside. Peri care given before transferring from recovery to mom/baby unit. Female infant delivered 5/25/16 0837 via C-section. Apgars 9/9. 2 arteries and 1 vein noted. No lanugo present, vernix on head and upper body. Placenta manual extraction 0838. No placental abnormalities noted. EBL 600 mL. Recovery: Fundus U@U, firm. Light rubra lochia. Perineum swollen. Dressing dry and intact. Urine output via Foley 60-90 mL/hr.

Additional Data: Pt’s previous C-section in 2015 was an emergency section due to non-reassuring fetal status AEB persistent late decels. Family has little to no help with childcare. LMP 9/1/15, EDD 6/1/16, EGA 39wks, Total weight gain 35 lb. Plans to breastfeed. BRP until spinal. Neonate put on mother for skin to skin contact in recovery room 35 minutes after birth. Neonate latched on to breast and breastfed for over 1 hour after birth. Neonate’s blood glucose was 52 (acceptable) 30 minutes after first feeding.

Substance Use: (ie. Tobacco alcohol, street drugs, over-the-counter) Denies tobacco, ETOH, and illicit drug use. Patient stated she took Tylenol OTC PRN for headaches.

Present History: Admitting Medical Diagnosis:

A. Why client is in hospital: Repeat C-section

B. Admitting Diagnosis Information: Patient is 39 weeks pregnant with gestational diabetes that has had a previous C-section. Repeat C-section per MD order.

Definition/Etiology/Pathophysiology:

A C-section is a surgical procedure used to deliver a baby through incisions in the mother's abdomen and uterus. A C-section could be planned ahead of time if any complications arise during the pregnancy or after a previous C-section (Citation).

A C-section can be performed for many reasons including: labor isn't progressing, non-reassuring fetal status/hypoxia, breech or transverse presentation, multiple gestation, placental problems, umbilical cord problems, obstruction, and/or previous C-section (Citation).

Trial of labor after cesarean (TOLAC) and vaginal birth after cesarean (VBAC) can be attempted if: the patient has one previous C-section and a low uterine incision, an adequate pelvis, no other uterine scars or previous uterine rupture, a physician who is able to do a C-section is available throughout active labor, and in-house anesthesia that can be available quickly for an emergency C-section if indicated (Davidson, London and Ladewig, 2016). There is 0.1-0.7% risk of uterine rupture, in comparison to a 0% risk of uterine rupture with a repeat C-section.

Clinical Manifestations/signs and symptoms:

A repeat C-section is not without risks. It is important to make sure the patient understands the risks of a repeat C-section. These risks include: blood loss, abnormal placentation, surgical injury to the bowel or bladder, adhesions, post-surgical complications, longer hospitalizations, increased cost, and hysterectomy (Davidson, London and Ladewig, 2016).

Medical Management:

Physicians will typically schedule a repeat C-section between 39-42 weeks. A C-section before 39 weeks should only be performed as medically necessary. This is at the discretion of the physician and depends on the patient’s surgical and prenatal history/complications. We must inform the patient and support person of: what is going to happen, the reason for the procedure, and what sensations may occur. It is important to note that a C-section, even a repeat C-section is a surgical procedures and all facility surgical protocol must be followed (Citation).

Past History/Secondary Diagnosis : Diet controlled gestational diabetes

Definition/Etiology/Pathophysiology:

Gestational diabetes is insulin resistance that is generally diagnosed during the second trimester between 24 and 28 weeks gestation. The first screening is a 50g- 1 hour glucose tolerance test. The diagnostic test is the 100g- 3 hour glucose tolerance test. The blood has an excess amount of glucose because of the insulin resistance and the glucose not being broken down and moved into the correct places in the body. Oftentimes GDM can be controlled by a regime of diet and exercise only, however in some patients that will not be enough. In patients where diet and exercise is not enough to control their GDM they will require insulin and/or an antidiabetic oral medication such as metformin. GDM will usually subside after delivery; however, these individuals now have an increased risk of type 2 diabetes in the future (Gestational diabetes, 2014).

The placenta produces high levels of many hormones during pregnancy, many of which actually impair the action of insulin in the cells. This in turn will cause the elevation of the serum glucose level. During pregnancy a slight elevation of the blood glucose after meals is considered normal, while a major increase in the blood glucose is an indication to investigate further as there may be a problem. In the first trimester there is little to no effect on the insulin in the body, however during the second trimester the need of insulin is increased. During this time patients with GDM do not make quite enough insulin, even with the extra amount, and in turn the blood glucose is high (Gestational diabetes, 2014).

It is important to remember that a patient with GDM has a high possibility of giving birth to a macrosomic neonate. A macrosomic neonate is one that is 9 pounds and greater.

Clinical Manifestations/signs and symptoms:

Patients who have an increased risk for gestational diabetes are those who are overweigh pre-pregnancy, over the age of 25, have a previous history of GDM, had a previous neonate that has weighed 9 pounds or more at birth, glycosuria, polycystic ovarian syndrome, and patients at risk for type 2 diabetes. Testing for GDM can be performed in two stages or one single stage. The two stage diagnostic test is with a 50g glucose load followed by a 100g oral load only if the first stage’s outcome was a blood glucose level of 130-140mg/dl or higher. The single stage diagnostic test is with a 75g oral glucose tolerance test. It is important to monitor for signs of hyperglycemia and hypoglycemia (Venes, 2013).

Signs of hypoglycemia include: fatigue, dizzy, restless, hungry, or unusually irritable; have difficulty concentrating; or have spontaneous episodes of sweating, palpitations, tremor, or nausea. Severely low blood sugar produces delirium, violent behaviors, obtundation, seizures, coma, and, occasionally, death. Some patients who have treated their diabetes mellitus with insulin for many years may lose the normal ability to recognize symptoms of low blood sugar (Venes, 2013).

Signs of hyperglycemia include: frequent urination, increased thirst, blurred vision, fatigue, and headache. The later signs, especially if the hyperglycemia is not treated include: fruity-smelling breath, nausea and vomiting, shortness of breath, dry mouth, weakness, confusion, coma, and abdominal pain (Citation).

Medical Management:

The goal of managing diabetes is to keep the blood glucose levels as close to normal as safely possible. This is done by monitoring the blood glucose multiple times a day; sometimes this could be before meals and at bedtime. It is important to always monitor the blood glucose to ensure it is not too high, or even too low (Citation).

Dietary management and physical activity are usually the first steps a physician will urge a patient to take to try to combat diabetes. Educating the patient on the importance of diet and exercise is also important. Diet and exercise can help control gestational diabetes effectively in many cases. These are non-pharmacological ways of controlling diabetes. Insulin therapy is an injection of insulin subcutaneously. The four major types of insulin are: rapid-acting, short-acting, intermediate-acting, and long-acting. Oral diabetes medications are also sometimes taken in combination with insulin if necessary. For patients controlling their GDM by diet and exercise we must educate them on the signs and symptoms of hyperglycemia. For patients that are controlling their GDM with oral medications and insulin it is important to teach them the signs and symptoms of hypoglycemia (Venes, 2013).

List of Medications

Medication Name	Indication	Actions	Contraindication	Side Effects	Nursing Implication
Pitocin 30units/500mL IV rapidly infused after placenta delivery. (Citation).	Postpartum control of bleeding after expulsion of placenta.	Stimulates uterine smooth muscle, controls postpartum bleeding.	Anticipated nonvaginal delivery, hypersensitivity.	Coma, Seizure, fetal ICH, fetal asphyxia.	Assess VS frequently and continuously throughout infusion. Monitor electrolytes. Monitor contraction strength, intensity, and duration. Teach patient that they should expect contractions similar to menstrual cramps.
Complete RFprenatal 90-1mg q day (Citation).	Prenatal multivitamins and preconception vitamins .	Contains fat soluble vitamins and most water-soluble vitamins. Prevents deficiency or replacement in patients whose nutritional status is in question. Folic acid is also for the prevention of neural tube defects.	Hypersensitivity to preservatives, colorants, or additives, including tartrazine, saccarin, and aspartame. Use cautiously with patients with anemia of an undetermined cause.	Urine discoloration, allergic reactions to preservatives, additives or colorants.	Assess patient for signs of nutritional deficiency before and throughout therapy. Educate patient on the importance of vitamins and folic acid.
clindamycin 900 mg IV (Citation).	Prophylaxis for reduced incidence of wound infection.	Inhibits protein synthesis in susceptible bacteria at the level of the 30s ribosome	C-diff, liver impairment, diarrhea, alcohol intolerance.	C-diff associated diarrhea, dizziness, headache, vertigo, nausea, vomiting, rash, uticaria, erythema multiforme, toxic epidermal necrosis.	Monitor bowel sounds, assess for hypersensitivity, assess for infections. Lab considerations: CBC w/diff, bili, CPK, ALT, AST. Inform patient that taste is bitter and to call HCP if you develop diarrhea, abdominal cramping, fever, or bloody stools and not to treat with antidiarrheal without asking their physician. Advise patient to report signs of superinfection.
gentamicin 100 mg IV (Citation).	Prophylaxis for reduced incidence of wound infection.	Inhibits protein synthesis in susceptible bacteria at the level of the 50s ribosome.	Hypersensitivity to gentamycin previously.	Ataxia, vertigo, ototoxicity, nephrotoxicity, muscle paralysis, hypersensitivity reactions	Assess VS frequently, monitor I&O’s, and monitor renal function. Lab considerations: monitor BUN, creatinine, AST, ALT, and bili. Educate patient to drink plenty of fluids, and on signs of superinfections. Instruct patient to report signs of hypersensitivity, tinnitus, vertigo, hearing loss, rash, dizziness, or difficulty urinating. Advise female patient to notify HCP if pregnancy is planned or suspected or if breastfeeding.
Hydromorphone PCA (Citation).	Moderate to severe pain	Binds to opiate receptors in the CNS to alter the perception of painful.	Hypersensitivity, respiratory, Acute or severe bronchial, paralytic ileus, acute, mild, intermittent, or postoperative pain (extended-release only); prior GI surgery or narrowing of GI tract, opioid non-tolerant, severe hepatic impairment.	Confusion, sedation, dizziness, dysphoria, euphoria, floating feeling, hallucinations, headache, unusual dreams, blurred vision, diplopia, respiratory depression, hypotension, bradycardia, constipation, dry mouth, nausea, vomiting, urinary retention, flushing, sweating, physical dependence, psychological dependence, tolerance.	Assess BP, pulse, and respirations before and periodically during administration. Assess pain. Do not give if respirations are under 12. Assess LOC. Explain therapeutic value of medication prior to administration to enhance the analgesic effect. The antagonist is Narcan. Advise patient to call for assistance when ambulating because it may cause drowsiness or dizziness. Change positions slowly to minimize orthostatic hypotension.
Bicitra 500mg sodium citrate/334mg citric acid/5mL oral 4 times a day (Citation).	Neutralize gastric pH	Neutralizes gastric acid, converted to bicarb to increase blood pH.	Renal insufficiency, sodium restriction, HF, toxemia of pregnancy, edema, untreated HTN.	Diarrhea, fluid overload, hypernatremia (severe renal impairment), hypocalcemia, metabolic, tetany.	Assess for signs and symptoms of alkalosis. Teach patient to take as directed and increase fluid intake. Educate to patient to take as directed- missed doses should be taken within 2 hr. Do not double doses.

Labs and Diagnostic Test:

Labs and Diagnostic Test	Purpose/ Indications	Normal Values	Client Result	Interpretation of abnormal results
Hgb (Citation)	Measures how much hemoglobin is in your blood. Hemoglobin transports oxygen throughout the body. They will check this in order to make sure the patient didn’t lose too much blood.	Females: 12-16gr/dl	8.9gr/dl *low	Patient is at greater risk of fluid volume deficit and shock. This value is before delivery and follow up labs should be done to see if blood product administration is necessary.
Platelets (Citation)	This blood test is done to make sure there is no excessive bleeding or clotting. Platelets are the part of blood that helps the blood clot (Platelet count, 2013).	150,000 – 400,000	191,000	WNL
Potassium (Citation)	Potassium is a very important electrolyte because of its role in cardiac function.	3.5-5.1 mmol/L	3.4* low	Patient’s potassium is borderline low. This could be simply because there has not been enough potassium in the patient’s diet. Potassium is important for a number of reasons, one of the most important is cardiac function.
WBC (Citation)	Measures the number of white blood cells in the blood. This test is performed to find out if an infection is present or an allergic reaction is occurring.	4,500-10,000	6,000	WNL

Nurses Note

0800- Assessment completed on patient

Subjective info

Objective info including vitals set, most recent labs, etc.

Full head to toe listed out

List any other time that additional assessment was done (ex: follow up assessments, like all other fundal assessments postpartum. State-

0900- reassessed fundus: at the umbilicus, firm and midline.

End with your signature

Signature

References

Davidson, M. R., London, M. L., & Ladewig, P. W. (2016). Olds' maternal-newborn nursing & women's health across the lifespan (10th ed.). Boston: Pearson Education, Inc.

Gestational Diabetes. (2014, April 25). Retrieved June 10, 2016, from http://www.mayoclinic.org/diseases-conditions/gestational-diabetes/basics/causes/con-20014854

Gestational Diabetes. (2014, April 25). Retrieved June 10, 2016, from http://www.mayoclinic.org/diseases-conditions/gestational-diabetes/basics/definition/CON-20014854

Kee, J. L. (2010). Laboratory and diagnostic tests with nursing implications. Upper Saddle River, NJ: Pearson.

Platelet count: MedlinePlus Medical Encyclopedia. (2013, February 2). Retrieved June 10, 2016, from http://www.nlm.nih.gov/medlineplus/ency/article/003647.htm

Vallerand, A., & Sanoski, C. (2015.). Davis's drug guide for nurses (Fourteenth ed.). F.A. Davis Company.

Venes, D. (2013).  Taber's cyclopedic medical dictionary (Ed. 22, illustrated in full color / ed.). Philadelphia: F.A. Davis.

Wilkinson, J., & Wilkinson, J. (2014). Pearson nursing diagnosis handbook with NIC interventions and NOC outcomes (10th ed.). Boston, Mass.: Pearson

Evaluation

STG 1: Goal met, discontinue. Patient utilized deep breathing to relieve anxiety before C-section

STG 2: Goal met, continue. Patient utilized call light 3 times in 1 hour before surgery to talk to staff about her feelings and anxiety.

LTG 1: Not met, continue. Patient is still hospitalized and has not been discharged since plan of care.

Assessment:

0711: Pre-surgical: 138/86, 87, 20, 98.6, 98% room air

Met patient, went over plan of care and labs. Patient verbalized anxiety about body image (scars) and low hgb level.

0735: Physician came in to speak with patient.

1108: Pt is 2 hours post repeat C-section. VS 132/88, 87, 20, 98.6, 97% room air. Pt rates pain 0 on a 0/10 PS. Lungs clear bil, S1 and S2 heard with no extra sounds, RRR. Trachea midline, no JVD noted. 20g IV in R AC. Hydromorphone PCA IV is hooked up but patient has not used any at this time. Baby girl breastfed 1.5 hours in recovery room, no assistance with latching needed. No redness or heat noted on breasts, pt denies breast pain. Fundus U@U, firm. Pt voiding via Foley catheter 60-90 mL/hr of light, clear urine. Last BM 5/23, pt states it was normal for her and free of pain, no flatus post op. Lochia light flow, rubra, free of clots, no odor noted. Incisional dressing is dry and intact. No hemorrhoids noted. Negative Homan’s sign. No clonus or pain associated with dorsiflexion of feet bil. DTR +3. Pt is able to move all 4 extremities freely. Pt and family educated on transfer to mom/baby within about 15 minutes, -JI, SN

Medications

Pitocin

Complete RFPrenatal

Clindamycin

Gentamycin

Hydromorphone

Bicitra

24 year old female.

Repeat C-section due to previous emergency C-section.

Interventions

STG 1: Teach patient deep breathing, guided imagery, and/or distraction.

STG 2: Educate patient on signs and symptoms of anxiety and how to utilize call light and how to verbalize anxiety to care team.

LTG 1: Encourage open communication and educate patient that her feeling are valid.

Rationale

STG 1: Teaching patient ways to self-control anxiety will help her to know it is possible without medication.

STG 2: Patient will be aware of signs and symptoms of anxiety and will understand how to call care team if it worsens.

LTG 1: Shows patient and the family that you care and that their feelings matter to you.

(Citation).

Nursing Diagnosis #1

Anxiety r/t surgical procedure and low hgb AEB patient verbalizes anxiety to nurse (Wilkinson & Wilkinson, 2014).

Plan - NOC: Coping: Personal actions to manage stressors that tax an individual’s resources.

STG 1: Patient will demonstrate anxiety self-control AEB using relaxation techniques before surgery.

STG 2: Patient will verbalize a decreased level of anxiety before surgery.

LTG 1: Patient will communicate needs and negative feelings appropriate by follow up appointment.

Labs

WBC Count 6,000 (WNL)

Hemoglobin- 8.9 (Low)

Hematocrit- 28.3% (Low)

Platelets- 191,000 (WNL)

Potassium- 3.4 (Low)

Evaluation

STG 1: Not met, continue. Patient refused to write down her strengths before surgery.

STG 2: Not met, continue. Patient has not verbalized a willingness to utilize behavioral health resources by discharge.

LTG 1: Not met, continue. It has not been four weeks since plan of care.

Assessment:

0711: Pre-surgical: 138/86, 87, 20, 98.6, 98% room air

Met patient, went over plan of care and labs. Patient verbalized anxiety about body image (scars) and low hgb level.

0735: Physician came in to speak with patient.

1108: Pt is 2 hours post repeat C-section. VS 132/88, 87, 20, 98.6, 97% room air. Pt rates pain 0 on a 0/10 PS. Lungs clear bil, S1 and S2 heard with no extra sounds, RRR. Trachea midline, no JVD noted. 20g IV in R AC. Hydromorphone PCA IV is hooked up but patient has not used any at this time. Baby girl breastfed 1.5 hours in recovery room, no assistance with latching needed. No redness or heat noted on breasts, pt denies breast pain. Fundus U@U, firm. Pt voiding via Foley catheter 60-90 mL/hr of light, clear urine. Last BM 5/23, pt states it was normal for her and free of pain, no flatus post op. Lochia light flow, rubra, free of clots, no odor noted. Incisional dressing is dry and intact. No hemorrhoids noted. Negative Homan’s sign. No clonus or pain associated with dorsiflexion of feet bil. DTR +3. Pt is able to move all 4 extremities freely. Pt and family educated on transfer to mom/baby within about 15 minutes, -JI, SN

Medications

Pitocin

Complete RFPrenatal

Clindamycin

Gentamycin

Hydromorphone

Bicitra

24 year old female.

Repeat C-section due to previous emergency C-section.

Interventions

STG 1: Encourage patient to write down her strengths. Give patient a pen and paper.

STG 2: Educate patient on behavioral health services in her area and teach her to notify her physician if she has post-partum depression symptoms.

LTG 1: Talk with patient about expected body changes prior to surgery.

Rationale

STG 1: Giving a pen and paper and encouraging her to write down her strengths will help build up self-esteem. This can also be used to gauge what she is thinking about herself to see if we will need some sort of behavioral health consult.

STG 2: Giving patient these resources lets her know they are out there to help her. Talking about post-partum depression signs shows patient what the signs are and helps her and her loved ones to recognize the warning signs before it can get worse.

LTG 1: Talking with patient about expected body changes can help prepare her on what she may experience.

(Citation).

Nursing Diagnosis #2

Disturbed body image r/t surgery AEB patient verbalizes that she is afraid her scar will look worse this time (Wilkinson & Wilkinson, 2014).

Plan - NOC: Self- Esteem: Personal Judgement of self-worth.

STG 1: Patient will identify three personal strengths within 2 hours.

STG 2: Patient will express willingness to use behavioral health resources by discharge.

LTG 1: Patient will verbalize acceptance of body changes within 4 weeks.

Labs

WBC Count 6,000 (WNL)

Hemoglobin- 8.9 (Low)

Hematocrit- 28.3% (Low)

Platelets- 191,000 (WNL)

Potassium- 3.4 (Low)