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PATRICK HENRY COMMUNITY COLLEGE CARE PLAN FOR NURSING 118: MATERNAL/CHILD HEALTH POST-PARTUM Student Name: Brittany Wood Date of Clinical: 11-2-10 Date Submitted: 11-4-10 Instructor Use Only: Satisfactory___ Unsatisfactory__________________ Date__________________________ Instructor: _______________________________________ Student Review Signature: __________________________ DEMOGRAPHIC DATA: Room Number: 260 Client Initials: CP TPAL: 2-0-0-1 Age: 24 Admission Date: 11-2-10___________________ Marital Status: D Gravida: 2 Para: 1 Aborta: 0__

Last Menstrual Period: Patient could not recall LMP

Estimated Date of Confinement (EDC) by dates: ___________ by sono: 11-06-10______ Surgery and Date: Repeat Cesarean-Section & Tubal Ligation______________________ Physician: Dionne Piggott, MD Pediatrician for newborn: Armstrong

Past Medical History: C-section, Gallbladder Removal, Foot Surgery________________

Prenatal Complications: None_______________________________________________

Allergies: (Type of Reaction): PCN (Penicillin) resulting in a rash.__________________

Did patient attend any childbirth preparation classes? Antenatal Medications: Zantac (Ranitidine OTC) 150 mg PO q evening for Reflux._____

Nursing Procedures Completed on Admission to L & D: IV insertion and prep for scheduled Cesarean Section (Unable to observe)_________________________________

Special Concerns of Family: None____________________________________________ LABOR: Nurses on duty in L & D: Crystal, Tammy, and Brandy___________________________ Time of onset: N/A Spontaneous: N/A Induced: N/A________________________

Pitocin Augmentation: Given Post-Op 150 mL/hr NS 1000 30 units Pitocin (RT hand)__ Time of Rupture of Membranes: 8:02 Dilation on Admission: N/A Presentation: N/A Spontaneous or Artificially: AROM__ Station: N/A_______

Effacement: N/A

Weeks Gestation: 39 weeks 3 days________

Date and Time of Delivery: November 2, 2010 @ 8:02____________________________ Type of Delivery: Cesarean Section Number of Hours in Labor: N/A Episiotomy/Lacerations: None____ Stage I: N/A Stage II: N/A Stage III: N/A

Analgesia: N/A___________________________________________________________ Anesthesia: Spinal Block___________________________________________________ Use of Assistive Devices (Forceps, Vacuum Extractor): N/A_______________________ Maternal Complications: N/A________________________________________________ Fetal Distress or Complications: N/A during delivery Hypoglycemic upon NB assessment Estimated Blood Loss at Delivery: 700 mL Sex of Newborn: Male Apgar Scores: 1-minute: 7 5-minutes: 9_____

Breast/Bottle Feeding: Enfamil_____________________________________________ What factors influenced feeding choice? Choice was related to c-section delivery. The patient stated I just got cut from one side to the other I dont want to have the child on my boob!

LAB/XRAY PROCEDURE Rubella Titer

DIAGNOSTICS RESULTS IMMUNE o

NURSING IMPLICATIONS Positive for rubella IgG antibodies by ELISA or chemiluminesence (>10IU/ML, immunity) Indicates a current or previous exposure or immunization to rubella. When testing for IgG antibody seroconversion between acute and convalescent sera is considered strong evidence of a current or recent infection. (10-14 day interval between acute and convalescent sample) Assess patients test knowledge Explain purpose and reason for the test Interpret test outcome and counsel appropriately Advise women of childbearing age to get immunized before becoming pregnant Immunization is contraindicated during pregnancy Patients who test positive are naturally immune to further rubella infections Blood typing to identify Rh-NEG women and ABO group for compatibility Intervention for Rh- NEG woman is to receive Rh immunoglobin (RhoGAM) prophylaxis.

o o o o

o o o o

Blood Type and Rh

Blood Type: AB Rh: Positive

4 o Identification for type O women for consideration of ABO incompatibility in neonatal jaundice. An elevated number of white blood cells are called leukocytosis. This can result from bacterial infections, inflammation, leukemia, trauma, intense exercise, or stress. Counts that continue to rise or fall to abnormal levels indicate that the condition is getting worse. Counts that return to normal indicate improvement. Pregnancy in the final month and labor may be associated with increased WBC levels. Decreased hematocrit indicates anemia, such as that caused by iron deficiency or other deficiencies. Further testing may be necessary to determine the exact cause of the anemia. Other conditions that can result in a low hematocrit include vitamin or mineral deficiencies, recent bleeding, cirrhosis of the liver, and malignancies. The most common cause of increased hematocrit is dehydration, and with adequate fluid intake, the hematocrit returns to normal. However, it may reflect a condition called polycythemia verathat is, when a person has more

WBC

11.6 HIGH

o o

Hgb & Hct

Hgb: 11.5 g/dL Hct: 34.1%

5 than the normal number of red blood cells. This can be due to a problem with the bone marrow or, more commonly, as compensation for inadequate lung function (the bone marrow manufactures more red blood cells in order to carry enough oxygen throughout your body). o Pregnancy usually causes slightly decreased hematocrit values due to extra fluid in the blood. o Decreased BUN levels normally occur in late pregnancy because of increased plasma volume (Physiologic hydremia). o The decreased creatinine in the urine is most likely related to the shock and dehydration of the body related to cesarean section birth. o Follow up UA should be completed to monitor levels for abnormal levels. o Provide patient education on the viruses. o Explain and answer any questions and/or concerns. o If pregnant. (There are now treatments that can greatly reduce the risk that a pregnant woman who has HIV will give the virus to her baby.) o A healthy individual has no antibodies to HIV. However, a negative screening test means only that there is no evidence of disease at the time of the test. o It is important for those who are at increased risk of HIV

Urinalysis

BUN: 6 Low Creatinine: 0.45 Low

HIV/Hepatitis Screen

NEGETIVE

6 infection to have screening tests performed on a regular basis to check for possible exposure to the virus.

Group Beta Strep Culture Results

POSITIVE

Group B streptococcus is a bacterium that is present as part of the normal flora in the vagina and gastrointestinal areas of 10% to 30% of women. When it is present in the vagina during delivery. In this case, it can spread to infect the uterus, amniotic fluid, urinary tract, and any incision made during a cesarean section. At delivery, when the baby passes through the birth canal, the bacteria can be inhaled or ingested. Infected infants may display symptoms within 6 hours of birth or as late as 2 months of age. If untreated, the baby may become septic, develop pneumonia, suffer hearing or vision loss, or develop varying degrees of physical and learning disabilities. To best assess the risk of infecting the baby at delivery, the pregnant woman is screened for Group B strep between 35 and 37 weeks of gestation. Specimens from the mothers vaginal and rectal areas are collected, and within 24 to 48 hours the

7 laboratory can determine if Group B strep bacteria are present. If the bacteria are present, or if the woman goes into labor before testing can be completed, it is recommended that she receive antibiotics intravenously during labor.

Chlamydia/Gonorrhea/ Syphilis/Herpes

NEGETIVE

o o

Assess past medical history for risk factors indicating any of the STDs, This will ensure that spread of the infection is prevented as much as possible. Gonorrhea, Chlamydia, and syphilis are three common sexually transmitted diseases (STDs) caused by bacterial infections. In a pregnant woman, these diseases can lead to a miscarriage or infect the baby before or during delivery. The baby may then have serious health issues such as infections of the eye, joints, or blood; blindness; or breathing problems. Some of these problems are life threatening. An STD also endangers the womans health. The best approach is for the woman to receive antibiotics to help clear up

8 the bacterial infection before the pregnancy or before delivery. Chlamydia and gonorrhea tests detect the actual bacteria in the sample. Some tests use a urine sample or cervical swab. If the test is positive, the person has a current STD infection that requires treatment. The syphilis test is a blood test. It detects an antibody produced by the body in response to the infection. The test does not distinguish between a current or past infection and, if it is positive, confirmatory testing will be required. A negative test result usually means that the woman is not currently infected; however, it is possible that an infection is too new to detect. Some states require all women to be screened for syphilis during delivery.

LAB/XRAY PROCEDURE

RESULTS

NURSING IMPLICATIONS N/A

Pertinent Ultrasound Results

N/A

Other pertinent labs or radiology studies

N/A

N/A

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MEDICAL THERAPY
TREATMENT RATIONALE NURSING RESPONSIBILITIES

Intravenous Fluids:
Lactated Ringers (LR) 1000 mL

150 mL/hr NS 1000 30 Units Pitocin 150 mL/hr

LR: This medication is an intravenous (IV) solution used to supply water and electrolytes (e.g., calcium, potassium, sodium, chloride), either with or without calories (dextrose), to the body. It is also used as a mixing solution (diluent) for other IV medications. Lactated Ringers Injection is indicated for parenteral replacement of extracellular losses of fluid and electrolytes as required by the clinical condition of the patient.

Assessment: Clinical evaluation and periodic laboratory determinations are necessary to monitor changes in fluid balance, electrolyte concentrations and acid-base balance during prolonged parenteral therapy or whenever the condition of the patient warrants such evaluation Monitor for therapeutic response Normal lab values: RBC, WBC, H&H, electrolyte levels Improved fluid volume status Increased tolerance to activities Monitor for adverse reactions: Reactions which may occur because of the solution or the technique of administration include: o Febrile response o Infection at the site of injection o Venous thrombosis or phlebitis extending from the site of injection o Extravasation o Hypervolemia If an adverse reaction does occur: o Discontinue the infusion o Evaluate the patient o Institute appropriate therapeutic countermeasures o Save the remainder of the fluid for examination if deemed necessary

11 The doctor will give specific directions concerning withholding food and fluid before surgery. Typically, the patient may eat solid food until supper, but can have nothing by mouth (NPO) beginning at midnight before surgery. This is implemented to reduce the risk of aspiration during the surgical procedure. Patients also may become nauseous r/t anesthesia so food is contraindicated because it can cause the patient to vomit. o o o o o Assure that the order is followed. Place the NPO sign outside the patient's room. Instruct the patient of the importance and the reason for being NPO. Remove the water pitcher and the drinking glass. Clearly mark the diet roster.

Diet: Regular Diet Last food consumption: 11-1-10 2205 (ice cream) NPO after 12:00 A.M. 11-2-10

12 MEDICATIONS
MEDICATION/DOSAGE/ ROUTE/FREQUENCY RATIONALE

NURSING RESPONSIBILITIES
o o o Patient education is important for patients with nerve blocks Continuous assessment of motor and sensory functions are vital Obtain enough assistance with transfer of patients first time out of bed postoperatively

Spinal Block: In Operating Room for anesthesia during Cesarean Section Delivery o Bupivacaine (Marcaine) o Morphine (Duramorph) o Fentanyl (Actiq, Duragesic, Fentora, Ionsys, Sublimaze)

Epidural anesthesia is regional anesthesia that blocks pain in a particular region of the body. The goal of an epidural is to provide analgesia, or pain relief, rather than complete anesthesia, which is total lack of feeling. Epidurals block the nerve impulses from the lower spinal segments resulting in decreased sensation in the lower half of the body. Epidural medications fall into a class of drugs called local anesthetics, such as bupivacaine, chloroprocaine, or lidocaine. They are often delivered in combination with opioids or narcotics, such as fentanyl and sufentanil, to decrease the required dose of local anesthetic. This way pain relief is achieved with minimal effects. These medications may be used in combination with epinephrine, fentanyl, morphine, or clonidine to prolong the epidurals effect or stabilize the mothers blood pressure.

Duramorph administration should be limited to use by those familiar with the management of respiratory depression. Rapid intravenous administration may result in chest wall rigidity. The most serious adverse experience encountered during administration of Duramorph is respiratory depression and/or respiratory arrest. This depression and/or respiratory arrest may be severe and could require intervention Overdoses may cause respiratory depression, coma and death. Patient education on medication administration and Therapeutic use Monitor patient for signs of adverse effects Minor side effects include: constipation, diarrhea, fatigue, headache, insomnia,

Ranitidine OTC (Zantac): Q evening for Reflux 150 mg PO o The current recommended adult oral dosage is 150 mg or 10 mL of syrup (2 teaspoonfuls of syrup equivalent to 150 mg of ranitidine) twice a day.

Ranitidine blocks the action of o histamine on stomach cells, and reduces stomach acid production. Ranitidine is useful in promoting healing of stomach and duodenal o ulcers, and in reducing ulcer pain. Ranitidine has been o effective in preventing ulcer recurrence when given in low doses for prolonged periods of

Nursing Interventions
Obtain patient history: Previous bleeding disorders Family history of bleeding disorders Past experiences during Cesarean section procedure (If procedure is a repeat) Risk factors for excessive bleeding Medications that could potentially cause bleeding complication Normal diet (including beverages) Assess vital signs frequently to monitor: B/P Heart Rate O2 Sat Temperature Other Assessments: Assess urine output Monitor IV fluids infused pre and intraoperatively Monitor for signs of lightheadedness and or dizziness Monitor active fluid loss from wound drainage, tubes, bleeding, and vomiting Maintain accurate intake and output record postoperatively and be sure to account for IV fluids. Monitor electrolytes for abnormal values Maintain adequate IV flow rate and be sure to monitor for signs of overload Goal Met AEB: Patient maintained vital signs within normal range. Estimated Blood Loss during procedure of 700 ML Weight loss r/t the delivery of the newborn (9lbs 13.3 oz) Patient showed no signs of dizziness or lightheadedness Patient showed willingness to comply with orders for fluid intake postoperatively.

Evaluation

In some patients it may be necessary to administer ZANTAC 150-mg doses more frequently. Dosages should be adjusted to individual patient needs, and should continue as long as clinically indicated. Dosages up to 6 g/day have been employed in patients with severe disease.

NURSING DIAGNOSES (MINIMUM OF 3)

time. In doses higher than that used in ulcer treatment, ranitidine has o been helpful in treating heartburn and in healing ulcer and o inflammation of the esophagus resulting from acid reflux (reflux esophagitis). 13

muscle pain, nausea, and vomiting. Major side effects are rare & they include: agitation, anemia, confusion, depression, easy bruising or bleeding, hallucinations, hair loss, irregular heartbeat, rash, visual changes, and yellowing of the skin or eyes.

Encourage patient to drink prescribed fluid amount during postoperative phase Place fluids within reach Provide fresh water and or ice chips Only give fluids if ordered by physician

Nursing Interventions
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Evaluation

Nursing Diagnosis

Subjective & Objective Data

Risk for Fluid Volume Deficit r/t surgical procedure 2nd Scheduled Cesarean Delivery
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Goal Met AEB: Patient free of infection as of 11:00 11-210. No purulent drainage or edema noted upon inspection of incision, and IV sites WBC count was 11.6 (HIGH), WBC is commonly slightly elevated after delivery via cesarean section because of the bodies response to the surgical incision. Vitals remained within normal limits during the post operative period Catheter site clean with no signs of irritation noted upon inspection. Patient verbalized that they were comfortable and having no pain r/t the catheter.
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Goal Patient maintains adequate fluid volume AEB: - Estimated Blood Loss <1000 ML - Normotensive blood pressure - Heart rate less than 100 BPM - Consistency of weight

Assessments: Inspect IV site for irritation, redness, and edema. Wash hands prior to contact with IV devices. Clean IV ports with alcohol swab before attaching syringes or tubing to prevent contamination of ports. Ensure proper administration and documentation of meds or fluids given. Reassess frequently after med administration to ensure therapeutic effect and to monitor for adverse effects. Inspect incision thoroughly for approximated edges, redness, edema, drainage, and foul odor. Wash hands before coming in contact with the patient to prevent spread of organisms. Report any changes in condition immediately to Physician for further instruction. This helps early intervention if there is an infection that could potentially be dangerous. Monitor labs frequently to evaluate changes in ranges of WBC. WBC shows how serious the infection is related to the range in the lab work. Higher numbers on labs indicate the infection is more serious because there is more WBC fighting the infection. Assess Catheter site for irritation and discomfort Provide proper hygiene for patient
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Patient underwent Cesarean delivery @ 7:30 A.M. 11-210 Repeat procedure with large quantity of scarred tissue and Tubal Ligation. Patient weighed 247 lbs, which prolonged surgical procedure. During surgery the Physician began to make an incision into the uterine wall. Upon first attempt to make the surgical incision the uterine wall began to bleed. The excessive bleed was related to the large amount of scarred tissue that had formed from the first cesarean delivery. The bleed was controlled and subsided after cauterizing the affected area. Estimated Blood Loss: 700 ML The Physician explained that due to her weight and scarred tissue the procedure took much longer than a normal cesarean delivery. This put the patient at increased risk for fluid volume deficit because not only was she loosing blood during the procedure, she was also loosing fluid into the atmosphere through evaporation. Interstitial fluid can be due to prolonged opening of the body cavity. B/P: 122/63 HR: 75 RR: 16 Temp: 96.8 O2 sat: 99%

Nursing Interventions
Two IV devices -RT hand -LFT wrist

Evaluation

Nursing Diagnosis

Subjective & Objective Data

Assess condition of tissue surrounding incision as well as the rest of the body.

Indwelling Catheter inserted in OR prior to surgical procedure. Procedure: Bilateral Cesarean Section and Tubal Ligation

Note any changes in the following: Color Size Drainage Approximation of edges Odor If changes are noted be sure to assess for sings and symptoms of infection.

Goal Met AEB: Condition of impaired skin remains intact Minimal redness noted Slight amount of edema noted r/t the inflammatory process during postoperative period No pain noted upon assessment. Patient verbalized the feeling of pressure but stated that the pressure caused no pain in or around the impaired tissue (Incision).

Wash hands before touching the incision at all times. This helps to prevent the spread of infection and in keeping the incision clean.

Risk for Infection r/t IV site, Cesarean Incision, Indwelling Catheter, and Lumbar puncture 2nd to Cesarean Delivery.

Drainage is a normal part of wound physiology but needs to be differentiated from pus, which is a sign of infection.

Goal

Assess patients level of discomfort Clean incision as directed by physician to ensure proper hygiene.

Labs: WBC 11.6 High, the body after a surgical procedure fights off any infection or foreign organism introduced during the procedure. The body was also healing the incision that had made during the procedure. Elevated WBC can be a sign of infection, or that the body is fighting of infection.

Provide skin care if required for impaired tissue site.

Maintain sterile field when providing care to or around the surgical incision.

Administer antibiotics as ordered for pain and or to aide in healing of impaired tissue.

Patient remains free of infection as AEB: normal vital signs, and absence of purulent drainage from wounds, incisions, and tubes. 15

After postoperative clearance or recovery reposition patient frequently to prevent tissue breakdown upon bony prominences. This also promoted comfort which aides in the healing process of the patient.

Nursing Diagnosis Impaired Tissue Integrity r/t Incision 2nd Cesarean delivery

Subjective & Objective Data

Cesarean Section procedure with bilateral incision performed @ 7:30 A.M. 11-2-10. Incision well approximated with slightly reddish tint upon postoperative assessment. Minimal Edema noted r/t surgical procedure and the effects on the body. (Inflammatory response). Patient verbalized the feeling of pressure around surgical incision, but was unable to feel pain because the Spinal Block had not worn off completely.

Goal Patients condition of impaired skin remains intact with no redness, edema, or pain noted.

Spinal Block administered prior to surgery for anesthesia. Patient will be unable to feel sensation for up to 3-4 hours after injection. Altered sensation puts the patient at increased risk for impaired tissue integrity.

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