Care Plan Date: March 18th, 2018 Student Name: Megan Seiferling

Client Initials: OA Age: 33 Admission: 16 Jan 19 Blood Type: O+ Allergies: NKA Antepartum Assessment:
Assess Q6h
G4 -T0 -P0 -A3-L0 Gestation: 38 1/7 weeks – singleton Baby Active: yes 1. Pain/Vital Signs
Priority Assessments: See side box Dx: Cervical Insufficiency + Cord presentation Room: 8 2. Fetal HR
3. Cramping?
4. Discharge? Blood? Fluid?
V/S BP: 120/74 HR: 116 T: 36.8 RR: 16 No cramping, discharge, pain 5. Kick Counts >26 weeks

1 Nursing Dx: Risk for Cord Compression on Fetus 2 Nursing Dx: Risk for Anxiety + knowledge deficit
Reasoning/Evidence to Support: Reasoning/Evidence to Support:
- Cervical insufficiency - Stressful situation
- Labour can occur anytime now – tightening occurred on NST - Close to expected due date
- Breeched baby - Coming off strict bed rest - does not want to walk around as does not want to go
into labour “I have 1 week to go” – C-section happening this night @ 1900
Assess/Do/Teach/Re-assess:
Assess/Do/Teach/Re-assess:
1. Assess for SROM and contractions. If rupture of membranes occur:
a. Assess fetal heartrate 1. Explain the procedures, nursing interventions, and treatment regimen. Keep
Medicalb.
Hx: Check to see if you can see the cord communication open
c. Put mom in hands and knees position 2. Answer questions honestly, especially information regarding contraction pattern
d. Ring call bell and fetal status. Encourage verbalization of fears or concerns.
2. Assess Fetal monitor strips for any variable deceleration which can indicate cord 3. Monitor maternal vital signs and fetal heart rate
compression – Tightening Occurred 4. Teach the use of relaxation techniques
3. Teach the importance of letting nurses know if water breaks or any contractions are felt 5. Teach the importance of movement in pregnancy – encouragement
4. Teach the reasoning behind a caesarean section rather than an vaginal delivery

3 Nursing Dx: Risk for Clot development + DVTs 4 Nursing Dx: Risk for Constipation
Reasoning/Evidence to Support:
Reasoning/Evidence to Support:
- Pregnancy is a state of hypercoagulability due to alterations of coagulation proteins - Effects of progesterone on the bowels, decreased abdominal muscle tone
- Venous stasis also increases as dilation of lower extremity veins occurs followed by - Last BM March 17th
venous compression by the gravid uterus and enlarging iliac arteries - Decreased mobility due to previous strict bedrest
- Previous strict bedrest – anxious to increase mobility - Pt passing flatus
Assess/Do/Teach/Re-assess: Assess/Do/Teach/Re-assess:
1. Assess for and reports sign and symptoms of Deep Vein Thrombosis. If occurs,
1. Assess current activity level and tolerance. Include pain level every two hours
immobilize the patient and initiate bed rest to reduce risk of clot mobilization.
2. Encourage daily fluid intake of 2000-3000 ml/day
2. Administer anticoagulants as ordered to reduce the risk of additional clotting
3. Discourage positions that compromise blood flow.  Encourage ambulation with assist as tolerated. 
4. Provide elastic compression stocking.  Educate client about a general pattern of constipation following pregnancy. 
5. Check any sign of complication (Pulmonary embolism).
6. Obtain lab orders to monitor APTT, PT and INR.
7. Teach signs and symptoms to be aware of