Care plans are based on individual clients.

They are designed to allow the student to critically think about each client and develop
interventions for that specific client.

 If the student is assigned to postpartum (couplet care setting) their care plan should be on the postpartum mother.
 If the student is assigned to L&D their care plan should be on the laboring mother.
 If the student is assigned to the Nursery their care plan should be on the baby.
Neonatal information may be included when appropriate in the SBAR reports.

OB Care Plan
Student: Alexandria Casarez Date: 7/7/2020

Course: 432-CC Instructor: Jasmine Gayongala

Clincial Site: online Client Identifier L.S. Age: 28

Reason for Admission: Patient was addmitted to the hospital for induction of labor due to preclamsia.

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

The patients has a diagnosis of preeclampsia.The pathophysiology of Signs and symtoms in a patient with preeclampsioa includes
preeclamsiam begins in the placenta and is resolved when the placenta is protineuria, and hypertension after 20 weeks of of gestation in a
expelled. It is cause by disruptions in placental perfusion and endothelial woman that had not previouly had these conditions (Wilson et. al,
cell dysfunction (Wilson et. al, 2018). Risk factors for preeclampsia 2018). My patient is presenting with elevated blood pressure upon
include nulliparity, age of greater than 40, pregnancy with assisted initial assessment and has elevated protein in her urine.
reproductive techniques, family history of preeclampsia, obesity,
gestational diabetes mellitus, preeclampsia in previous pregnancy, chronic
hypertension, and type 1 diabetes mellitus (Wilson et. al, 2018).
Assessment Data
© 2018. Grand Canyon University. All Rights Reserved. Rev 2.17.18
Subjective Data: Patients states that she is not feeling well, and states that “something is wrong”. She is complaining of blurry vision and
shortness of breath.
VS: (upon arivail) Labs: Diagnostics:
T : 37.2 C RBC-2.53 L (5-6.25) Daignostics for this patient includes a category 2 fetal
monitoring strip.
BP: 128/83 HGB- 6.8 L (>11)
HR: 110 HCT- 24.5 L (>33%)
RR: 18 Platelets- 100,000 L (150,000-400,000)
O2 Sat: 99% on room air Urine Protient to Creatinie ratio- 300 mg H
VS: (one hour later) Listed in paranthesis is the normal lab values for
T : 37.4 C a pregnant woman. These abnormal labs listed
above can be seen in pregnant women who have
BP: 100/ 50 or preeclamsia.
HR: 110
RR: 20
O2 Sat: 93% on room air

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Assesment: Orders:
Neuro-Patient was drowsy and oriented x4 patients speech was clear Ambulation as tolerated after anesthesia wears off.
and appropriate. Patients pupils were equal, round, reactive to light, and
accommodation was notted. Eyes opened to verbal commands, and Regular diet.
patient complained of visial disturbances Monitor the paitients intake and output.
Cardio- Heart sounds were auscultated for all valves, S1 and S2 were Assess vital signs every hour.
noted with regular rate and rhythm. Patients radial pulses were noted at
2+ billaterally, and pedal pulses were noted at 2+ billaterally.
Respiratory- Patients O2 was 99% on room air, patients lung sounds
were clear throughout all lobes with shortness of breath.
GI/GU- Patient has distended look to stomach due to having recently
delivered a baby, and patient has difficulty identifying when she has to
urinate.
Vaginal exam- 7 cm dialated, 90% effacement, and -2 station.
Negative Homan’s sign.

Medications
ALLERGIES: NKDA

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 Name Dose Route Frequency Indication/Therapeuti Adverse Effects & Nursing
c Effect Side Effects Considerations

4 mu/in IV Continuous Induction of labor and term, Coma, seizures, intracranail Assess character
Oxytocin and potpartum control of hemorrhage, asphyxia, hypoxia, frequency and duration
bleeding. hypotension, and arrythmias of uterine contractions,
resting uterine tone,
and fetal heart rate
frequently.
Monitor the maternal
BP frequently and FHR
continuously durring
administration.
50 ml/ hr IV Continuous Treatment and prevention of Drowsiness, decreased respiratory rate, Monitor the newborn
Magnesium hypomagnesmia, prevention arrythmias, hypotension, diarrhea, and for hypotension,
Sulfate of seizures associated with muscle weakness hyporeflexia, and
severe ecclampsia and respiratory depression
preeclampsia if the mother had
received mag sulfate.
Tylenol 1000mg PO Q6hrs PRN Treatment of mild pain and Hepatotoxicity, anxiety, HA, fatigue, Preform a pain
fever. dyspnea, hypertension, and constipation assessment including
type, location, and
intensity pior to
administrations and 30
minutes after
administration
1000 ml IV Continuous Source of water and Abdominal pain, swelling, dizziness, Monitor patients vital
Lactated electrolyte used for headache, fever, and confusion. signs including BP
ringers hydration. durring administration.
Penicillin G 3 mil. Units/ 50 ml IV Q4 hrs Treatment of infection and Seizures, diarrhea, epigastric distress, Observe for signs and
Potassium prohpylaxis. nausea, vomiting, rash, urticaria, pain, sypmtoms of
and phlebitis at the IV site anaphlaxis which
includes rash, pruritus,
larengeal edema, and
wheezing. Discontinue
drug if reaction occurs.

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Goal
Client or family focused.
Priority Nursing Diagnosis (including rationale for choosing this as the priority diagnosis)
Altered tissue perfusion to the placenta related to hypertension as evidence by the diagnoses of preeclampsia.
The goal for this patient
includes increasing oxygen
to the placenta.
Secondary Nursing Diagnosis: Risk for infection related to the labor process as evidence by the paitents SROM with thick meconium at 1700.
The goal for this patients
is to reduce the risk of
Nursing Diagnoses and Plan of Care
Expected Outcome
Measurable, time-specific,
reasonable, and attainable.
Expected outcome will be
that the patient will
understand the need to
maintain perfusion to the
placenta and will
partcipate in the
interventions to increase
perfusion by the end of
the shift.
Expected outcomes for
this patient includes is that
the patient will maintain
good hygiene, patient will
Intervention(s)
Nursing or interprofessional
interventions.
1.Educate the patient to
report any signs of vaginal
bleeding, uterine
tenderness, abdominal
pain, and decreased fetal
activity.
2. Position changes for the
mother.
3. Note fetal response to
medications administered,
like MgSO4.
4. Utilize an
ultrasonography to assist
with the assesment of
placenta size.
1. Monitor and record the
patient’s themperature
every 2 hours (because the
membranes are ruptured.)
Rationale
Provide reason why intervention
is indicated/therapeutic.
Provide references.
1. Educating the patients to
report the signs is
important because
immediate attention is
required.
2. Position changes are
important because it can
increase perfusiomn to the
placenta.
3. Noting the fetal response
is important because
depressant effects on the
fetus can include decreased
fetal HR and RR.
4. Monitoring the placental
size can aid in
dertermining the health of
the placenta.
1. Recording the patients
temperature is important
because temperature
elevation is an early sign
Evaluation
Was goal met? Revise the
plan of care according the
client’s response to current
plan of care.
The goal for this
patients was met, by
educating the patient
about her condition,
asking her to report any
signs of harm, and
having the patient
change her position.
The goal for this patient
was meed by decreasing
the risk of infection by
monitoring the patient and
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infection. remain free from infection, 2. Use continuous fetal of infection. keeping them clean and
and patients temperature monitoring to assess FHR 2. Monitoring is important dry.
will remain within normal and variability, report HR because FHR over 160
range for the remainder of greater than 160 and bpm and minimal
their hospital stay. variability under 3-5 beats/ variablity may indicate
min. maternal fever.
3.Maintian good patient 3. Kepping the area clean
hygiene by cleaning the and dry reduces the risk of
perineal area by wiping infection.
front to back and keep area
dry.
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.”

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 References
C, D.W.M.H.S.P.K.A.D.L.M. C. (2018). Maternal Child Nursing Care. [Pageburstls]. Retrieved

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

Phelps, L. (2017). Sparks and Taylor's nursing diagnosis reference manual (10th ed.). Hagerstown, MD: Lippincott, Williams &

Wilkins/Wolters Kluwer. ISBN-13: 9781496347817

Vallerand, A., Sanoski, C., & Deglin, J. (2017). Davis’s drug guide for nurses (15th ed.). 

Philadelphia, PA: F.A. Davis.