OB Care Plan

Student: Jessica McKeever Date: 05/22/2020

Course: OB Instructor: Professor Gayongala

Clincial Site: Banner Del Webb Client Identifier: L.S. Age: 28

Reason for Admission: Patient L.S. is 39 weeks and 2 days pregnant for induction of labor due to preeclampsia. Her GTPAL (2, 2, 0, 0,
1) and her vitals are stable.

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

Preeclampsia is a pregnancy complication that if left untreated, could be Some clinical manifestions include excess protein in your urine,
fatal for both the mother and the baby. It is characterized by a proteinuria severe headaches, changes in vision, nausea or vomiting, decreased
concentration greater than 1+ on a dipstick, a systolic blood pressure urine output, thrombocytopenia, impaired liver function, or
greater than 140 mmHg, and a diastolic blood pressure greater than 90 shortness of breath (Preeclampsia, 2020).
mmHg (Uzan, 2011). These criteria make monitoring the mother’s blood L.S. presented with extreme lethargy, unable to take deep breaths,
pressure very important and she should see her doctor immediately if she mildly blurry vision, and shortness of breath.
shows any common symptoms such as severe headache, upper abdominal
pain, blurred vision, or shortness of breath. Some risk factors include
chronic hypertension, kidney disease, diabetes, obesity, previous
preeclampsia.

Assessment Data
Subjective Data: While taking her vitals, she rated her pain 5/10 and that she had a spontaneuous rupture of membranes while she was at her
home last night. One hour later, she states that “something is wrong” and reports having mildly blurry vision and shortness of breath.

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

VS: (05/19/2020 @0800) Labs: Diagnostics:
T : 37.2 RBC: 2.5 (normal for third trimester 2.72- 4.43)  Blood tests
 Urine analysis
BP: 128/82 Rationale: low blood cell count is common due
to the increase of plasma which causes the  Fetal ultrasound
HR: 110  Nonstress test or biophysical profile
dilution of red cells
RR: 18
Hemoglobin: 6.8 (normal for third trimester 9.5-
O2 Sat: 99% on room air 15)
VS: (05/19/2020 @1500) Rationale: low hemoglobin is common due to the
T : 37.5 increase of plasma which causes the dilution of
red cells
BP: 100/50
Hematocrit: 24.5 (normal 28- 40)
HR: 110
Rationale: low hematocrit is common due to the
RR: 22 increase of plasma which causes the dilution of
O2 Sat: 93% on room air red cells

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Assessment: Orders:
- Neurological: Alert and oriented x4; speech was clear and  Full code
comprehensible; pupils were equal, round, and reactive to light;  Fall precautions
approximately 3 millimeters bilaterally; patient was cooperative and  VS Q4h
answered questions appropriately  Morse fall scale Q12h
 Banner delerium assessment Q12h
- Respiratory: Patient SPO2 was 99% on room air; auscultated lung
 Educate on pressure ulcer prevention
sounds were clear in all lobes bilaterally; patient had no present cough
 VTE education
- Skin: Skin color was consistent with ethnicity; warm and intact with  Oral care BID
no wounds  Raise head of bed BID
 Aspiration risk Q12h
- Cardiac: Heart rate had regular rhythm; heart rate BP was 128/82; S1  Fetal monitoring
and S2 sounds auscultated; cap. refill was less than 3 seconds; radial
pulses were plus two bilaterally; pedal pulses were plus two bilaterally;
no edema present; no JVD present
- Gastrointestinal/ Genitourinary: Abdomen was round, soft, and non-
tender; Bowel sounds auscultated in all 4 quadrants and indicated
normal active bowel sounds; no catheter in place
- IVs/ Monitoring Lines: 20g peripheral IV on right hand; 20g
peripheral IV in left AC
Her vaginal exam showed that was 7cm dilated; 90% effacement, and –
2 station. She had a spontaneuous rupture of membrane with thick
meconium present at 1700 05/18/2020. Her contractions are Q5 min and
the fetal heart tones are 156 with moderate variability.

edications
ALLERGIES: NKDA

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

Oxytocin 40 mL/ hr IV Continuous Indicaiton: Induction of Maternal: coma, seizures, - Fetal maturity,
labor; facilitation of hypotension, presentation, and pelvic
threatened abortion hypochloremia, adequacy should be
hyponatremia, increase assessed prior to
Therapeutic effect: uterine motlilty, painful administration of oxytocin
Induction of labor; contractions, decrease in for induction of labor
control of postpartum uterine blood flow - Monitor maternal BP and
bleeding pulse frequently and fetal
Fetal: intracranial heart rate continuously
(Vallerand, Sanoski, & hemorrhage, asohyxia, throughout administration
Deglin, 2017) hypoxia, arryhythmias - This drug occasionally
causes water intoxication.
(Vallerand, Sanoski, & Monitor patient for signs
Deglin, 2017) and symptoms such as
drowsiness, listlessness,
confusion, headache,
anuria; notify physician or
other health care
professional if they occur

(Vallerand, Sanoski, &

Deglin, 2017)

Magnesium 50 mL/hr IV Continuous Indication: Drowsiness, decrese in - Monitor pulse, BP,

sulfate Treatment/prevention of prespiratory rate, respirations, and ECG
hypomagnesemia; arrhythmias, bradycardia, frequently throughout
treatment of hypotension, diarrhea, administration of
hypertension; muscle weakness, parenteral magnesium
prevention of seizures flushing, sweating, sulfate. Respirations

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 associated with severe hypothermia should be at least 16/min
eclampsia, pre- before each dose
eclampsia, or acute (Vallerand, Sanoski, & - Monitor newborn for
nephritis Deglin, 2017) hypotension, hyporeflexia,
and respiratory depression
Therapeutic Effect: if mother has received
Replacement in magnesium sulfate
deficiency states; - Monitor serum
resolution of eclampsia. magnesium levels and
renal function periodically
(Vallerand, Sanoski, & throughout administration
Deglin, 2017) of parenteral magnesium
sulfate

(Vallerand, Sanoski, &

Deglin, 2017)

Tylenol 1000 mg PO Q6h PRN Indication: Treatment of Agitation, anxiety, - Assess type, location,
for pain mild pain and fever headache, fatigue, and intensity prior to and
insomnia, atelectasis, 30– 60 min following
Therapeutic Effect: dyspnea, constipation, administration
Analgesia; antipyresis hypertension, - Evaluate hepatic,
hepatotoxicity, urticaria, hematologic, and renal
(Vallerand, Sanoski, & Stevens-Johnson Sydrome function periodically
Deglin, 2017) during prolonged, high-
(Vallerand, Sanoski, & dose therapy
Deglin, 2017) - Increased serum
bilirubin, liver enzymes
and prothrombin time may
indicate hepatotoxicity

(Vallerand, Sanoski, &

Deglin, 2017)

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Lactated 1000 mL; 125 IV Continuous Indication: Maintenance Heart failure, pulmonary - Assess fluid balance such
Ringers mL/hr of fluid and electrolyte edema, edema, as intake and output, daily
status in situations and hypernatremia, weight, edema, lung
hydration hypervolemia, sounds throughout therapy
hypokalemia,
extravasation and irritation - Monitor serum sodium,
Therapeutic Effect: at IV site potassium, bicarbonate,
Replacement in and chloride
deficiency states and (Vallerand, Sanoski, & concentrations and acid-
maintenance of Deglin, 2017) base balance periodically
homeostasis. for patients receiving
prolonged therapy
(Vallerand, Sanoski, &
Deglin, 2017) - Monitor serum
osmolarity in patients
receiving hypertonic saline
solutions
(Vallerand, Sanoski, &
Deglin, 2017)

Penicillin G 3 million units/ IV Q4h Indication: Treatment of Seizures, diarrhea, - Obtain a history to
Potassium 50mL a wide variety of epigastric distress, nausea, determine previous use of
infections vomiting, and reactions to
pseudomembranous penicillins,
Therapeutic Effect: colitis, interstitial cephalosporins, or other
Bactericidal action nephritis, rash, urticaria beta-lactam antibiotics
against susceptible - Observe patient for signs
bacteria (Vallerand, Sanoski, & and symptoms of
Deglin, 2017) anaphylaxis such as rash,
(Vallerand, Sanoski, & pruritus, laryngeal edema,
Deglin, 2017) wheezing; discontinue
drug and notify physician
or other health care
professional immediately
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 if these symptoms occur.
Keep epinephrine, an
antihistamine, and
resuscitation equipment
close by in case of an
anaphylactic reaction
- Monitor serum sodium
concentrations in patient
with hypertension or HF.
Hypernatremia may
develop after large doses
of penicillin sodium.

(Vallerand, Sanoski, &

Deglin, 2017)

Nursing Diagnoses and Plan of Care

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): Ineffective breathing pattern
Rationale: Her lungs might be filling with fluid which is why she is reporting feel shortness of breath.

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Patient will have normal Patient will have 1. Observe for breathing 1. Unusual breathing 1. Met- When taking
respiration rate. respiration rate of 16- 20 patterns. patterns may imply an vitals every four hours,
by end of shift. 2. Utilize the pulse oximetry underlying dysfunction. her breathing patterns
to check oxygen saturation 2. The pulse oximetry can where observed for any
and pulse rate. detect alterations in abnormalities.
3. Assess the position that oxygentaion and abnormal 2. Met- Her oxygenation
pulse count. percent and pulse rate
the patient assumes for
3. Having a pregnant where taken every four
breathing.
women lie flat on her back hours.
can increase dyspnea and 3. Met- The patient was
(Sparks & Taylors, 2017) encouraged to reamin
causes compression of the
vena cava. from lying flat on her
back and this was
(Sparks & Taylors, 2017)
enforced during each
encounter and corrected
if necessary.
(Sparks & Taylors,
2017)

Secondary Nursing Diagnosis: Risk for infection related to rupture of membranes

Rationale: The rupture of the amniotic sack no longer acts as a barricade to prevent bacteria from entering the birth canal.

Patient remains free from Patient will have vital 1. Administer prescribed 1. Administer the correct 1. Met- Her Penicillin G
infection. signs withing the normal antibiotics at appropriate antibiotics can ensure that Sodium was administered.
limits and absent of signs times. if there are bacteria that 2. Unmet- Due to her
and symptoms of infection 2. Minimize the amount of are getting into the birth preeclampsia, vaginal
by end of shift. vaginal exams performed. canal, that they are exams were frequently
eliminated by the performed to monitor the
3. Proper hand hygiene
medicine. progression of labor.
should be performed in
front of the client. 2. Although vaginal exams 3. Met- Hand hygiene was
are sterile, there is still a
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 (Sparks & Taylors, 2017) possibility that bacteria done before touching the
could be introduced into client to minimize the
the birth canal. spread of bacteria.
3. Hand washing is the (Sparks & Taylors, 2017)
best way to prevent the
spread of bacteria. This is
especially important to do
since the bacteria could
potentially harm the baby.
(Sparks & Taylors, 2017)

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.”

References
Phelps, L., Ralph, S., & Taylor, C. (2017). Sparks & Taylors nursing diagnosis reference manual (10th ed.). Philadelphia, PA:

Wolters Kluwer.

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Preeclampsia - Symptoms and causes. (2020, March 19). Retrieved from [Link]

conditions/preeclampsia/symptoms-causes/syc-20355745

Uzan, J., Carbonnel, M., Piconne, O., Asmar, R., & Ayoubi, J. M. (2011). Pre-eclampsia: pathophysiology, diagnosis, and

management. Vascular health and risk management, 7, 467–474. [Link]

Vallerand, A. H., Sanoski, C. A., & Deglin, J. H. (2017). Davis's drug guide for nurses (15th ed.). Philadelphia, PA: F.A. Davis

Company

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