Ob Care Plans

Topics: Childbirth, Nursing care plan, Sudden infant death syndrome Pages: 8 (2011 words) Published: June 20, 2013
Natalie Sullivan
Nursing Care Plans

Care Plan: Post Partum

Patient’s initials: SR
Date of Care: 5/6/2013

Assessment Data:
* G1P1
* C/S on 5/5/2013 at 1832
* Incision at suprapubic region
* Staples mid right side to end of left side of incision
* Steri strips on right side of incision r/t to removal of 5 staples because staples were loose * Pt complaining of pain in lower abdomen
* Pt complaining of “uncomfortableness” at incision site * Scant bleeding at incisional site on steri strip

Nursing diagnosis: risk for fall r/t epidural and anesthesia aeb c/s delivery

Goal: pt will remain free of falls for remainder of clinical shift and stay at hospital

Nursing interventions and rationales:
I. Teach client and family about the fall reduction measures that are being used to prevent falls * Prevention begins with education, the more the client and families know about how to prevent falls the more likely they will comply (i.e. leaving 2 head side rails up on clients bed, leaving floor free of clutter) and the safety of the client will be in everyone’s best interest. II. Call light in reach of patient:

* Leaving the call light near the patient at all times helps prevent injury by not having the patient get up to reach the call light, it also helps the patient reach the nurse faster when they need help, have a question, or are in need of something. III. Nurse will assist patient to bathroom and when ambulating in room: * Client will need support to ambulate and use restroom when she is ready and anesthesia as worn off, clients legs will be weak and she will be tired and experiencing pain around incisional area and need assistance when using the restroom to prevent falls and injury.

Goal met, patient remained free of falls while duration of stay. Side rails remained up while patient in bed; patient used call light for help to ambulate to restroom. Patient’s room remained free of clutter.

Nursing diagnosis: risk for bleeding r/t cesarean delivery aeb surgical incision

Goal: client will maintain stable vital signs with minimal blood loss during stay at hospital

Nursing interventions and rationales:
I. Assess patient surgical incision and perineal area frequently for any signs of excess bleeding * Excess bleeding can be signs of hemorrhage, monitoring incisional site and perineal area, including under the butt and back, are ways to catch any heavy and concerning bleeding. II. Educate client about calling the nurse when bleeding occurs at incisional site * Educating patient about bleeding after birth is important so that she has an understanding of what is normal and not normal III. Assess patient's fundal height and assess for firmness or bogginess of fundus * One of the major causes of hemorrhage is uterine atony, assessing the fundus for firmness or bogginess is important. Making sure to massage the fundus first then have the client pee is important in preventing hemorrhage.

Goal met; patient repeated back education received from nurse about s/s of bleeding and using call light; nurse checked incision site and perineal area for any bleeding. Bleeding was scant and regular, no excessive bleeding occurred.

Nursing diagnosis: risk for infection r/t surgical incision aeb cesarean delivery

Goals: client will remain free of infection and report any signs of infection during duration of stay at hospital

Nursing interventions and rationales:
I. Teach client signs and symptoms of infection such as redness, increased temp above 100.4, warmth and/or discharge from incisional site. * An increase in temperature is one of the first signs of infection, educating the patient about signs and symptoms is important in maintain the health of the client. Two-thirds of infections occur after discharge, making education of s/s important, so that...

References: Lowedermilk, D., Perry, S., Cushion K., & Alden, K. (2012). Maternity & women’s
health care. 10th edition. St. Louis: Elsevier Mosby.
Ackley, B.J. & Ladwig, G.B. (2011). Nursing diagnosis handbook: An evidence-based guide to planning care. 9th Edition. St. Louis: Elsvier Mosby.
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