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Clinical Week #
Labor/Delivery
Se
x:
Ag
e:
Roo
m:
Admitti
ng date:
29
4425
2/4/16;
18:40
K.R
Attending physician/treatment
Consultants seen during this hospitalization:
team:
Anesthesiologist
Jamie S. Januszyk, MD
Present diagnosis:
ER management:
Caesarean section due to prolonged
None
labor; Lack of progressive cervical
dilation
Allergies:
Code status:
Isolation status:
Amoxicillin
Full Code
None
Admission height:
Admission weight:
Arm band status:
157.48 cm.
89 kg
Red-Allergies
Communication needs:
Pt. speaks English
Past medical/surgical history:
None
Significant events during this hospitalization:
Caesarean Section due to prolonged labor; Lack of progressive cervical dilation
Tests or treatments impacting clinical days care:
None
Advance directives/ethical considerations: (DPOA, Hospice, DNR, Living Will, etc.)
Rev. 1/16
None
Pregnancy history:
Gravida: 1
Year
2016
Para T (Term): 1
Weeks
gestatio
n
41
Outcome
(SAB, IAB,
NSVD,
C/S)
C/S
P (Preterm): 0
Rev. 1/16
Health Assessments
Vital Signs:
Rev. 1/16
Time
_7:00__
a.m.
T
97.8 F; Oral
P
108;
Automatic
R
18;
Observed
B/P
110/62;
Automatic
Pulse Ox 97%
Pain
7
Score
__12:05_
p.m.
99.2 F; Oral
108;
Automatic
16;Observe
d
123/82;
Automatic
97 %
0
Rev. 1/16
2/5
2733.6
3000
2/6
1000.5
-266.4
1000.5
Interventions:
-Monitor input/output
Interventions:
-Monitor/Assess fall risk
-Educate pt. on fall risk related to epidural anesthesia
-Monitor to ensure pt. safety.
-Placed side rail up 2x, bed at lowest position and call
light within reach
Rev. 1/16
Interventions:
-Monitor glucose
Reproductive:
Pt. stated no reproductive history of problems
(Abortions or miscarriage).
Interventions:
-Place bed at lowest position to prevent falls, especially
when pt. is in recovery/post-op; Fall risk due to epidural
anesthesia
-Re-Assess fall risk and adjust plan of care accordingly
Interventions:
-Monitor for signs of hemorrhage
-Assess uterine firmness, location, position and
amount of lochia
-Monitor vitals every 15 mins. first hr., every 30
mins. second hr. and hourly third and fourth hr.
Then Q4-Q8 as prescribed by physician.
Rev. 1/16
Rev. 1/16
Results and
date
2/5/16
O
+
N/A
41; 12.5
Postpartum H&H
Rubella status
GBBS
WBC
RBC
Platelets
Newborn
Diagnostic
Data
Blood type (A, B,
O, AB)
Rev. 1/16
Normal Lab
Values
Immune
Negative
9.11
4.62
266
38-50; 12.116.4
38-50; 12.116.4
4.5-10.5
4-5.4
150-400
Rh factor (+ or
-)
Coombs test
Blood glucose
Cord blood
bilirubin
TCB/Serum
bilirubin (please
note whether
value is
transcutaneous
or serum)
Write in any
other NB labs
below:
Pharmacological Intervention
Medication
Pitocin
Dose, Route
and
Frequen
cy
30
units/500
ml, IV
Classificatio
n
Purpose/Mechanis
m of Action
Oxytocic
Rev. 1/16
Significant Side
Effects /
Adverse
Reactions
This pt. did not
show any signs
of sign effects or
adverse effects.
*Can cause
hypertension,
uterine
hypertonicity,
water
intoxication,
ergotism, cardiac
arrhythmias
Nursing Implications
Medication
Dose, Route
and
Frequen
cy
Classificatio
n
Purpose/Mechanis
m of Action
Cervidil
(Dinoprosto
ne)
10 mg,
Vaginal,
Once
Ondansetro
n
4 mg, PO,
Q4H
Antiemeti
c
Fentanyl
25 mcg, Inj.
IV push,
Once
Opioid
analgesic
Rev. 1/16
Significant Side
Effects /
Adverse
Reactions
Nursing Implications
*Can cause
uterine rupture,
fetal/ neonatal
death, glaucoma,
fetal distress,
decrease uterine
integrity.
This pt. did not
show any signs
of sign effects or
adverse effects.
*Can cause
constipation,
dizziness,
headache,
fatigue,
drowsiness,
diarrhea, fever
and urinary
retention.
This pt. did not
show any signs
of sign effects or
adverse effects.
*Can cause
nausea,
Medication
Ketorolac
(Toradol)
Dose, Route
and
Frequen
cy
30 mg, Inj.
IV push,
Q6H
Classificatio
n
NSAID/
Analgesic
Purpose/Mechanis
m of Action
Rev. 1/16
Significant Side
Effects /
Adverse
Reactions
vomiting,
dizziness,
decreased gastric
mobility and
respiratory
depression
Nursing Implications
*Can cause
anaphylaxis due
to
hypersensitivity,
nausea, GI
bleeding,
sedation,
hypotension or
hypertension,
rash, headache,
and edema
weakness.
-Monitor for respiratory
depression
12
labor: dilation, expulsion and placental delivery. There are also a myriad of other actions, before and during the process of
labor that the body takes in order to achieve parturition or the forcible expulsion of the fetus from the mothers uterus.
Beginning with contractions or the involuntary smooth muscle flexing of the uterus, the body begins its job of moving the
fetus into position for birth. These contractions begin as minor discomfort and gradually escalate into full discomfort. At this
time, the mother may choose pain relief from epidural injections that numb the lower extremities. Dilation of the uterus is the
opening and widening of the cervix to 10 centimeters. This is when contractions increase and the amniochorionic membrane
inside the uterus ruptures, releasing the amniotic fluid; can also be described as water breaking. The fluid aids not only in the
expulsion of the fetus, but also protects it from infection. If the water break too early, mothers are given antibiotics to protect
the fetus. In the third stage, expulsion; contractions push the baby through the birth canal and out into the world.
After delivery of the fetus, the body changes its focus toward the placenta. The placenta, is first shrunken down by a process
called myometrial retraction, then detaches itself from the uterine wall and with the help of uterine contractions is propelled
downward and out via the uterus.
13
Epidemiology:
Its not quite clear as induction of labor has become more of an elective procedure.
Etiology: (Risk factors as to why an induction of labor may occur)
You're approaching two weeks beyond your due date, and labor hasn't started naturally
Your water has broken, but you're not having contractions
There's an infection in your uterus
Your baby has stopped growing at the expected pace
There's not enough amniotic fluid surrounding the baby (oligohydramnios)
Your placenta has begun to deteriorate
The placenta peels away from the inner wall of the uterus before delivery either partially or completely (placental
abruption)
You have a medical condition that might put you or your baby at risk, such as high blood pressure or diabetes
Infection
14
Uterine rupture
Patient Prognosis:
Pt. had an induction of labor which was successful in starting labor but due to lack of cervical dilation and fetal decent, the pt.
had to have a caesarean section. Pt. had a successful c/s and delivered a healthy baby boy on 2/6/16; 07:29.
15
Nursing Diagnoses
Priority
1
Nursing Diagnosis
Acute Pain
Related to
Induction of Labor
As Evidenced By
Pt. verbalization of pain
7/10 on numerical scale
Anxiety/Fear
Caesarean Birth
Pt. verbalization of
anxiety/fear over
invasive surgery
Hemorrhage
Falls
Use of narcotic
analgesics/Epidural
Rationale
This would be my top priority for this pt.
This pt. had an induction of labor with
the use of Pitocin. The administration of
Pitocin causes the uterus to contract
and is painful.
This would be my second priority for
this pt. We must address any questions
or concerns about the procedure for the
pt. to help put them at ease.
Although hemorrhage is a big concern,
this pt. did not experience excessive
blood loss. We must continue to monitor
pt. post-op for any signs of hemorrhage.
This pt. may be at risk for infection due
to surgical incision. We must teach
proper handwashing to pt. in order to
avoid any infection of the incision site
post-op.
This pt. is a fall risk due to the use of
analgesics. We must monitor pt. and
ensure pt. safety. We must assess and
re-evaluate fall risk and adjust plan
accordingly.
16
_7:00__
a.m.
T
97.8 F; Oral
P
108;
Automatic
R
18;
Observed
B/P
110/62;
Automatic
Pulse Ox 97%
Pain
7
Score
Patient Outcome
(objective,
expected or
desired
outcomes, or
evaluation
parameters)
[Remember the
S-M-A-R-T
acronym]
- Patient will maintain
pain level at a 3/10 or
below for the
remainder of the shift
-Patient will have a
controlled level of
pain as evidenced by
the patient verbalizing
pain of 3 or less on a
pain scale of 0-10 by
the end of shift on
2/6/16.
Interventions/Implementation
s and Rationale
(specific nursing actions)
-Anesthesiologist
administered epidural which
will help with pain due to
labor
-Administration of Toradol; 30
mg, Inj. IV push, Q6H for
breakthrough pain post-op
Evaluation
(Include whether
outcome
was met or
unmet)
Outcomes met:
-Pt. verbalized
pain at 0 out of
10 prior to
transfer to postpartum unit
17
depression
-Implement comfort
measures such as adjusting
pillows
Pharmacological/nonpharmac
ological pain relief strategies
(Controlled breathing
techniques)
18
Assessment or data
collection relative to
the nursing
diagnosis
(Provide subjective and
objective assessments)
Patient Outcome
(objective,
expected or
desired
outcomes, or
evaluation
parameters)
[Remember the
S-M-A-R-T
acronym]
-Pt. will remain
relaxed prior and
during the scheduled
c/s 2/6/16; 07:00.
-Pt. will understand
what to expect during
and after the
procedure; 2/6/16;
07:00.
-Pt. will be relaxed as
evidenced by pt.
verbalize of being
relaxed and
understanding the
outcomes of the
procedure
Interventions/Impleme
ntations and
Rationale
(specific nursing
actions)
-Provide counseling
and moral support, as
needed
-Address any questions
or concerns promptly
to put pt. at ease
Evaluation
(Include whether outcome
was met or unmet)
Outcome Met:
-Pt. stated during
recovery period, I was
worried and everything
went well.
-Pt. stated
understanding
-Make sure all consents procedure and knew
are read, understood
what to expect after the
and signed
procedure
-Call or consult with
physician to make sure
pts. concerns are
appropriately
addressed
-Explained procedure
to pt. in order to put
19
References
ATI Nursing Education. (2013). RN pharmacology for nursing. Assessment Technological Institute, LLC.
Gulanick, M., & Myers, J. L. (2011). Nursing care plans. St. Louis: Elsevier Mosby.
Ralph, S. S., & Taylor, C. M. (2011). Nursing diagnosis reference manual. St. Louis: Wolters Kluwer Health| Lippincott Williams &
Wilkins.
Ricci, S.S. (2013). Essentials of maternity, newborn, and womens health nursing (3rd ed.). Philadelphia: Lippincott Williams &
Wilkins.
Osborn, K.S., Wraa, C.E. & Watson, A.B. (2010). Medical-surgical nursing: preparation for practice. Upper Saddle River: Pearson
Education, Inc.
20