Care Plan

Student: Makenna Tracy Date: 1/25/20

Course: NSG-432 CC Instructor: Instructor Curry

Clincial Site: Banner Del Webb Client Identifier: CV Age: 35

Reason for Admission:

CV was admitted for medical induction of labor – advanced maternal age (MIOL-AMA) and trial of labor after cesarian section (TOLAC). Her
gestational age is 40 weeks and 4 days.

Medical Diagnoses: (Include Pathophysiology and Risk Factors): Clinical Manifestation(s):

GBS+ CV’s clinical manifestations:
Group B streptococcus is a naturally occuring bacteria in the GI  Asymptommatic
tract and vagina of healthy, adult women. Although it is not
Expected maternal clinical manifestations:
harmful to adults, it can cause serious illness in infants born
vaginally.  Asymptommatic
Risk factors for infant: premature delivery, mother is a carrier, Expected infant clinical manifestations:
membrane rupture at least 18 hours before delivery, mother’s
 S/S can occur as early as 6 hours after delivery
temperature > 38°C
 Fever
Risk factors for mother: naturally occurs in 25% women  Difficulty feeding and breathing
worldwide  Lethargy
(Mayo Clinic, 2019)  Irritability
 Jaundice
(Mayo Clinic, 2019)

© 2018. Grand Canyon University. All Rights Reserved. Rev 2.17.18

 Assessment Data
Subjective Data: CV voiced her concerns about receiving an epidural due to experiencing paralysis for 3-5 days after her last delivery. She
had asked about nitrous oxide and if it were possible for her to recive that instead. She was also knowledgeable about her body because this was
her 8th pregnancy. She stated that she has long labors and her shortest time was 16 hours. She is also explained she gets anxious when she has to
be on one place for long periods of time.
VS: T : 36.9°C Labs: Diagnostics:
BP: 118/65 WBC US Preg Transvaginal
HR: 97  11.6  Date: December 4th, 2019
RR: 16  Normal: 3.4-9.6  Results: cervix is not dilated and measures 3-4 cm
 Rationale: WBC increases during the in length
O2 Sat: 97% with face second trimester and peaks in the third
mask
trimester
Pain: 8 (1-10 scale)
(Perry, Lowdermilk, Cashion, Alden, Olshansky,
et al, 2018)
Platelet
 144
 Not an abnormal level but it does cause
interest
 Rationale: pregnancy causes a natural
decrease in platelets; count will be
monitored for further decrease due to risk
of PPH
(Mayo Clinic, 2018)

Assessment: Orders:
PMH Foley Catheter
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PPH, low platelet count during pregnancy, preeclampsia, paralysis after Fetal heart monitoring
last epidural, VBAC x 5, twins, rape trauma
Supplemental O2 PRN
G: 8, T:5, P:1, A:1, L:7
Assisted ambulation
Neuro
I&O monitoring
LOC: A/O x 4 most of the day; experienced illusions briefly when
CBC
nitrous oxide gas was administered, nitrous has been discontinued
Lactated Ringers
PERRLA intact bilaterally
Discontinued: Nitrous Oxide-Oxygen
Speech is clear
Affect is anxious and irritable
Cardiovascular
Edema +1 in lower extremities bilaterally
Capillary refill: brisk < 3 second return
Pulses: radial is palpable +2, pedal is palpable +2
Heart tones: S1, S2 are present upon auscultation; no evidence of S3,
S4, or murmur
Respiratory
Lung sounds: clear in all lobes bilaterally
Respiratory effort: unlabored r/t fetal lightening
Oxygen status: 97% with face mask
Respiration rate: 16
GI

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Last BM: 1/22/20, color was appropriate, consistency was firm
GU
Voids without difficulty and frequently
Foley Catheter placed at 1500
Urine is yellow, clear
Sterile Vaginal Exam
Dilation: 8 cm
Effacement: 90%
Fetal station: -1
Fetal Heart Tones
FHR: 155 baseline
Mild variability with late decelerations
Reassuring strip was sen after supplemental O2 was administered to CV
Frequency of contractions
3-4 per 10 minutes
Membrane Status
Artificial rupture at 1030
Clear
Emotional Status
CV started her day seeming comfortable and upbeat. As the day

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progressed, she gradually became more anxious and irritable

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 Medications
ALLERGIES:
Penicillin, gluten, potatos, latex, nitrous oxide

Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing

Effect Considerations
Oxytocin (Pitocin) 2 mU IV Continous Induction of labor Most Frequent: increased Assess fetal
titrate q20-30 uterine motility, painful maturity,
minutes contractions presentation, and
Life Threatening: coma, pelvic adequacy
seizures; fetal intracranial prior to
hemorrhage and ataxia administration;
Other: hypotension, Monitor maternal
hypochloremia, BP, HR and FHR
hyponatremia, water after every
intoxication, abruptio titration;
placentae, decreased Advise patient to
uterine bloodflow, expect contractions
hypersensitivity; fetal similar to
arrythmias menstrual cramps
after administration
has begun
Clindamycin 900 mg IV Q8h Treatment of GBS+ Most Frequent: diarrhea Monitor CBC due
(Cleocin) Life Threatening: C. diff, to risk of
drug reaction with developing
easinophilia and systemic decrease WBC and
symptoms, erythema platelets;
multiforme, toxic Assess for
epidermal necrolysis hypersensitive
Other: dizziness, reaction;
headache, vertigo, Instruct patient o

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 arrythmias, hypotension, notify health care
bitter taste, N/V, rash, professional
urticaria, plebitis at IV immediately if
site diarrhea,
andominal
cramping, fever, or
bloody stools
develop;
Inform that the
bitter tast that may
occur is not
clinically
significant
Epidural Local 6 mL/hr Epidural PRN/continous Labor pains Life Threatening: Monitor BP, HR,
Anesthetics catheter seizures, cardiovascular and RR
collapse continuously while
Other: anxiety, dizziness, patient is receiving
headache, irrritability, medication;
blurred vision, tinnitus, Monitor sensation
arrythmias, bradycardia, before therapy
hypotension, tachycardia, starts and after
N/V, urinary retention, therapy ends;
pruritus, metabolic Advise patient to
acidosis, circumoral request assistance
tingling/numbness, during ambulation
tremor, chondrolysis, after admistration
allergic reaction, fever of therapy;
Insert foley
catheter to assist
with urine
elimination
(Synoski & Vallerand, 2017)
Nursing Diagnoses and Plan of Care
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 Goal Expected Outcome Intervention(s) Rationale Evaluation
Client or family focused. Measurable, time-specific, Nursing or interprofessional Provide reason why intervention Was goal met? Revise the
reasonable, and attainable. interventions. is indicated/therapeutic. plan of care according the
Provide references. client’s response to current
plan of care.
Priority Nursing Diagnosis (including rationale for choosing this as the priority diagnosis)
Acute pain related to Pitocin administration, contractions, and anxiety pertaining to the epidural and sitting still for too long as evidenced by her
pain level of 8 on a scale of 1-10 and subjective data.
Rationale: Acute pain is the priority diagnosis because
CV will express a decrease CV will experience 1. Assess CV’s pain 1. To obtain information The goal was somewhat
in the intensity of her satisfaction with her pain symptoms and administer and plan appropriate met.
discomfort. control during labor and pain medications as ordered nursing interventions and
delivery. 2. Explain the available to provide pain relief 1. CV’s pain symtoms
analgesics and anesthesias 2. Awareness of available were assessed and an
to CV and her support medications will reduce epidural was
person anxiety administered to provide
3. In the first stage of labor, 3. To decrease anxiety pain relief, however all
provide the patient with areas were numbed
diversional activities except for the perineal
area; due to this, CV’s
pain and anxiety
remained elevated and
she became irritable
2. Prior to the epidural
admisitration, the nurse
and anesthesiologist
explained different pain
medication options to
reduce anxiety
3. CV was also provided
with distraction
activities which relieved
some anxiety and pain
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Secondary Nursing Diagnosis:
Risk for infection related to artificial rupture of membranes.
CV will remain free of CV’s temperature will 1. Use strict sterile
infection. remain within the range of technique when applying
36.1°C – 37.2°C during scalp electrodes, inserting
labor and delivery. urinary catheters, or
performing a vaginal
examinations
2. After rupture of
membranes, minimize
vaginal examinations
3. After artificial rupture
of membranes analyze
color, amount, and odor of
amniotic fluid for presence
of blood or meconium
Definition of Client-Centered Care: Care that is unique to the age/developmental stage, gender, race, ethnicity, socio-economic
status, cultural and spiritual preferences of the individual and focused on providing safe, evidence based care for the achievement of
quality client outcomes.”
1. To reduce the likelihood
of nosocomial infections
2. To reduce the risk of
chorioamnionitis and other
uterine infection
3. Alterations in the
amnioic fluid may indicate
infection; meconium may
also indicate a
predisposition to
intrauterine infection and
fetal distress
The goal was met. CV
remained free of infection
during labor and delivery.
1. The risk of nosocomial
infection was decreased by
using strict sterile
technique
2. Uterine infection was
avoided due to the
minimization of vaginal
examinations after
membrane rupture
3. The amniotic fluid was
analyzed after rupture for
meconium or blood; the
fluid was clear of both
(Ralph & Taylor, 2017)
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 References
Mayo Clinic. (2018, April 3). Thrombocytopenia (low platelet count). Retrieved January 25, 2020, from

https://www.mayoclinic.org/diseases-conditions/thrombocytopenia/symptoms-causes/syc-20378293

Mayo Clinic. (2019, August 15). Group B strep disease. Retrieved January 25, 2020, from https://www.mayoclinic.org/diseases-

conditions/group-b-strep/symptoms-causes/syc-20351729

Ralph, S. S., & Taylor, C. M. (2017). Nursing diagnosis reference manual. Philadelphia: Wolters Kluwer Health/Lippincott Williams
& Wilkins.
Synoski, C. A., & Vallerand, A. H. (2017). Davis's drug guide for nurses 15th Edition. F.A. Davis Company.
Perry, S. E., Lowdermilk, D. L., Cashion, K., Alden, K. R., Olshansky, E. F., Hochenberry, M. J., Wilson, D., & Rogers, C. C. (2018).

Maternal child nursing care, 6th edition. [Pageburstls]. Retrieved from

https://pageburstls.elsevier.com/#/books/9780323549387/

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