NURSING CARE PLAN
Professor: Elyse Eiser
Nurs 316 L-A
235 LB / 5’1″
Temp (C/F Site)
Pulse Ox (O2 Sat)
Pain Scale 1-10
78 bpm /
97% Room Air
157 / 98
History of Present Illness including Admission Diagnosis
Chief Complaint (normal
& abnormal) supported with Evidence Based Citations
Physical Assessment Findings including presenting signs and
symptoms supported with Evidence Based
M.B is a
35 yo female who gave birth through C-Section at 38 weeks gestation to a baby
boy. She experienced pregnancy related Hypertension or Gestational
Hypertension in her third trimester as well as Partial Placenta Accreta which
was complete accrete in her earlier gestational age. Placenta accrete is a
result of attachment of the placenta to the part of uterus which has a scar
from previous c section surgeries or any uterine related surgery. Placenta
accrete occurs when the placenta attaches too deep in the uterine wall, but
it does not penetrate the uterine muscle. The exact cause of placenta accrete
is unknown but, it could be result of placenta previa or as mentioned
previous cesarean deliveries. The scars from multiple cesareans increases the
possibility of a future placenta accrete. (Americanpregnancyorg, 2017).
Hypertension is diagnosed when blood pressure is higher than 140/90 mm Hg in
readings, in a woman who had normal blood pressure prior to 20 weeks and has
no proteinuria. This could be related to hypertensions from previous
pregnancies, or being overweight. (stanfordchildrens.org, 2017)
HR: 78, BP: 157 /98, O2: 97% RA, RR: 18.
was A&O x 4 and English speaking. Communication was very easy and smooth
since M.B was fluent in English speaking. M.B’s breasts appeared normal with
no presence of cracking or bleeding. M.B has some difficulty in breast
feeding since her nipples were somewhat flat. she produced about 150 mL of
colostrum via breast pump, with her right breast producing more. She did not
have much Breast milk product since she has hypothyroidism. Hypothyroidism
could cause problem in breastfeeding such as low milk supply.
heart sound was regular, S1 and S2 heard. Lung sounds clear bilateral in all
fields and lower lobes. C-section incision site staples covered with steri-strips
with no signs of hemorrhage or active bleeding. The fundus was palpated, and
it was firm, and located midline with the umbilicus and about 1 cm below. She’s
had moderate lochia rubra, which is normal and safe. She’s had severed
constipation after her surgery and was given stool softeners to help with
bowel movements. Stool softener did not help, and she end up having enema.
M.B has voided without complications and any use of catheter. M.B. has developed
2+ edema on her legs but that was decreased after giving birth and multiple
voiding. M.B was negative for Homan’s sign; therefore, she does not show any
risk for DVT. M.B’s was very cooperative, happy, and accepting towards the
baby. M.B was spending lots of time interacting with her baby boy and trying
her best to breast feed despite the fact which she has no milk supply but
regardless she was trying her best. She’s had good amount of colostrum and
she’s had satisfactory projection.
Relevant Diagnostic Procedures/Results & Pertinent Lab
tests/ Values (with normal ranges),
include dates and rationales supported with Evidence Based Citations
Past Medical & Surgical History,
Pathophysiology of medical diagnoses
(include dates, if not
found state so)
Supported with Evidence
M.B’s CBC levels are all within normal range
except, for high WBC levels at 11.4,
HGB levels at 11.5, and HCT levels
at 37.6. The high WBC levels are expected to be normal in a pregnant patient,
after another screening test of WBC. The patient does not present infections
(Durham, et. al, 2014). RBC level was 4.58. The Hgb levels and Hct levees 37.6
are expected to be low, but her level is average. Platelet levels are 263.The
Hgb and Hct are supposed to be low during pregnancy because there is a higher
demand for iron in fetal development, which many pregnant women increase the
risks of developing iron-deficiency anemia (Durham, et. al, 2014). HgbA1c
levels were within normal range, at 6.2. Healthy HgbA1c levels are 5.0-7.0%.
Increased levels of glycated hemoglobin or A1C are normally found in patients
with un-well managed diabetes (Fischbach, et. al., 2015). M.B results for
Group B streptococcus is negative, Rubella is positive, Blood type Rh is A+,
STD was negative, Gonorrhea is negative, Chlamydia is negative, HIV is
negative, Syphilis is negative, Herpes is negative, Hepatitis B test result
is negative as well. M.B’s Blood Glucose Level was 104 mg/dL. Average blood
glucose levels for pregnant patients are between 70-110 mg/dL. Elevated blood
glucose levels are being results of unproperly management of blood glucose
levels accompanied by abuse of food that are high in carbohydrates, fats and
lack of physical activities in diabetic patients (Durham, et. al, 2014).
two previous C-Section with complete term pregnancy. She also experiences a
fetal demise in 24 weeks Gestational age. Fetal Demise is a result of death
of fetus in the uterus after 20 weeks gestational age. Symptoms include,
bleeding, cramping, loss of fetal movement. Possible cause of fetal demise
1) History of surgery to the cervix.
2) Use of illicit drugs, especially cocaine
3) Fetal abnormalities (genetic or
4) Uterine infection
5) Physical problems with the uterus,
such as fibroids or abnormalities in the shape of the uterus.
has hypothyroidism. Hypothyroidism is results of underactive thyroid gland
which means thyroid gland cannot make adequate thyroid hormones to keep
body’s metabolism running normally. Signs and symptoms of hypothyroidism are:
weight gain, anxiety, depression, cold intolerant, and dry skin.
Hypothyroidism in pregnancy is a big issue which could cause negative impacts
on fetal development. Since there are many hormonal changes within pregnancy,
thyroid hormones are highly effected in pregnancy as well. Thyroid function
changes during pregnancy due to the influence of two main hormones: human
chorionic gonadotropin, the hormone that is measured in the pregnancy test
and estrogen, the main female hormone. HCG can weakly turn on the thyroid and
the high circulating HCG levels in the first trimester may result in a
slightly low TSH which is called subclinical hyperthyroidism.
gland size could also be changed during pregnancy. It could increase inn
size. Managing thyroid hormones are very important during pregnancy. The
adverse effects of untreated hypothyroidism during pregnancy could result in,
under development of fetal brain, also it can have severe cognitive,
neurological and developmental abnormalities. (Thyroid.org, 2017)
Erikson’s Developmental Stage with Rationale
And supported by
Evidence Based Citations
& Psychosocial Considerations/Concerns (3) supported
with Evidence Based Citations
M.B is 35
years old therefore, her Erikson’s stage falls in intimacy vs. isolation
stage. This is where some individual finds that significant other to spend
their life with. They have this feeling which they feel like they might be
alone forever. An individual who goes through this stage successfully, may
feel that they are wanted and have that companionship they have been
searching for. On the other hand, an individual who does not successfully
complete this stage regardless of the reason, might feel as if he/she will be
alone forever because he/she has not found a companion yet. M.B is in the
intimate stage because she is successfully married with a supportive husband
and three kids who has been by her side. She appears happy with her marriage
life and family. She is successfully going through this stage and does not
feel as if she is alone or isolated. (simplypsychology.org, 2017)
M.B is an
Armenian Christian who is married for 6 yrs. and have three kids. She is stay
at home mother wo devote her full-time life to take care of her children. She
has a successful marriage life and appears to be happy with her family. She
is well English spoken and could communicate easily with her. She also speaks
English and some Farsi. She is very cooperative with staff and shows lots of
love to their new born son. She has two daughters. She also has a sense of
reliefe since, she experienced a fetal demise with a previous pregnancy which
was a baby boy. She strongly believes in God and practice her religion. She
also has a very strong character and she was up and walking the day after
C-Section to make sure she recovers fast and be able to go home.
Potential Health Deviations, Predisposing & Related
Factors; (At least two) Include three independent nursing interventions for each
(“At Risk for…”
Inter-professional Consults, Discharge Referrals, & Current Orders
(include diet, test, and treatments) with Rationale
supported with Evidence
Risk for infection related to
cesarean incision site
has delivery via caesarian section. She has an incision site on her lower
abdomen and this puts her on considerable risk for infection. It is very
important to keep the incision site clean and have daily dressing changes
with sterile technique. She and the staff have to make sure to keep the area
clean and dry to eliminate any bacterial growth around incision site.
Risk for fall related to use of
pain killers and Narcotics.
has caesarian section, she will have lots of pain in her incision site and
she will be using lots of pain medications and narcotics in order to tolerate
the pain specially the first 48 hrs. Staff must make sure the call light is
in reach for M.B and make sure the side rails are up.
Follow up appointment with OBGYN
two weeks Post-Op.
important to have a follow up visitation with OBGYN after C-Section to check
the incision site to make sure there are no complication or any infection
after the patient leaves the hospital and is not under direct care of Health
care staff. Also, it is important to assess the abdomen and uterus for any
port op complication such as hemorrhage or bleeding.
Follow up appointment with
has Hypothyroidism, it is very important to follow up with her Endocrinology
Specialist to make sure her thyroids functioning properly, and she is having
adequate metabolism to prevent weight gain. Also, having adequate thyroid
hormone function helps with production of mother’s milk supply.
Priority Nursing Diagnosis
(at least 2)
Written in three part
Measureable goal during your shift
(at least 1 per Nursing
and collaborative nursing interventions; include further assessment,
intervention and teaching
(at least 4 per goal)
Rationale Each must be
supported with Evidence
Goal Met, Partially Met,
or Not Met
Excess fluid volume
2. Related to physiological changes during
3. As evidenced by blood pressure 157/98 and a 2+
pitting edema, as well as imbalanced electrolyte levels.
will have decreased fluid volume, which in result will help stabilize blood
pressure and decrease edema.
Administer diuretics such as Lasix to help with fluid retention.
Administer antihypertensive medication
Monitor vitals q1hr.
Make sure patient will report any headaches or other signs that may be
indicative of a stroke.
diuretics will help the patient decrease the excessive water retention in the
body therefore, decreasing edema and blood pressure.
medication will help lower the patient’s blood pressure and decreases any
dangers associated with it such as stroke.
patient vital signs are important because any changes will indicate of an
adverse effect and could be taken care of properly.
patient to report any abnormal signs that could indicate danger is important
so that any life-threatening events may be prevented.
Goal has partially
met. Patient was able to void and edema began to disaapear. Also, after being
given antihypertensive medication, patient’s blood pressure went down to
desired range which was 128/85.
2. Related to C-section
3. As evidenced by patient unable to have a bowel
movement after C-Section procedure.
will have a bowel movement by end of shift.
Encourage the patient to ambulate as soon as possible.
Teach patient to consume foods high in fiber to promote GI motility.
Drink the permitted about of water since patient has excess fluid
ambulation will result in bowel movement of the GI system, therefore allowing
the patient to eliminate constipation.
foods high in fiber promotes GI motility and will help patient with ease of
passing the stool.
be absorbed by the feces and allow the patient to pass her stool much easier.
Goal has met.
Patient was able to have a successful bowel movement before discharging from
the postpartum unit.
Medications (with APA citations
Dose (& range)
If out of range, why?
Mechanism of action
Onset of action
Common side effects
specific to this patient
mineral and electrolyte replacements or supplements
treat or prevent seizures in severe preeclampsia.
1 to 2
g/hr by continuous infusion.
40 mg/ mL
anticonvulsant, magnesium depresses the CNS and blocks peripheral
neuromuscular impulse transmission by decreasing available
nausea, skin irritation/sensitivity. (DavisDrugsguid.com, 2017).
Monitor the patient for any adverse effects to the
Monitor fetal heart rate as well as patient vitals.
to lower patient blood pressure.
Q 12 hrs
blocks alpha and beta-receptors in vascular smooth muscle and beta in the
heart to reduce peripheral vascular resistance and blood pressure. (DavisDrugsguide.com,
decreased libido, headache, heartburn, indigestion, rash, stuffy nose,
Monitor effectiveness of medication by taking patient
vitals 30 min after administration.
patient has pain at the incision cite of her C-Section.
perception of and emotional response to pain at spinal cord and higher levels
of CNS by blocking release of inhibitory neurotransmitters, such as
acetylcholine. (DavisDrugsguid.com, 2017).
drowsiness, anxiety, drowsiness, relaxed and calm.
Patient has constipation so administering a stool softener
or encouraging fluids is important since a side effect is constipation.
Assess pain levels 30 min after administration and take
used to provide additional vitamins and nutrients that are needed for
takes places mainly in the duodenum and jejunum. Helps prevent iron-deficient
anemia and neural tube defects in neonates. (DavisDrugsguid.com, 2017).
Administer stool softener if patient continues to be
stool softener/ used to treat constipation.
Acts as a
surfactant that softens stool by decreasing surface tension between oil and
water in feces. This action lets more fluid penetrate stool, forming a softer
fecal mass. (DavisDrugsguid.com, 2017).
cramping, bitter taste, diarrhea, nausea.
Assess efficacy of medication by monitoring bowel
Being a Hypothyroid Mother and Nursing – Stop The
Thyroid Madness. (n.d.). Retrieved from
default – Stanford Children’s Health. (n.d.).
Erikson’s Psychosocial Stages of Development. (2017).
Retrieved from https://www.simplypsychology.org/Erik-Erikson.html
sulfate (IV, parenteral) | Davis?s Drug Guide. (n.d.). Retrieved from
Placenta Accreta: Symptoms, Risks and Treatment. (2012,
April 26). Retrieved from http://americanpregnancy.org/pregnancy-complications/placenta-accreta/
Pregnancy and Thyroid Disease. (n.d.). Retrieved from https://www.thyroid.org/thyroid-disease-pregnancy/
UC Davis Health, Department of Obstetrics and
Gynecology. (n.d.). Understanding Second or Third Trimester Loss | UC Davis
Obstetrics and Gynecology. Retrieved from https://www.ucdmc.ucdavis.edu/obgyn/services/FP/trimester_loss.html