Nursing 620C: OB Care Plan

Patient History
J.H. is a 25 year old, married woman whose primary language is English. J.H. had her last menstrual period on June 6th of 2007 giving her an estimated date of delivery of March 13th, 2008. She is Gravida 2 Para 0, and had received prenatal care while refraining from alcohol, tobacco, and any recreational drugs during her pregnancy. Her prenatal medications included a woman’s multivitamin and polysaccharide iron. J.H. has a blood type of A positive, is Rh positive, Rubella immune, negative for Hepatitis B, and positive for Group B Strep. She had no medical complications during her pregnancy, but did complain of increased urination, nausea, fatigue, and breast tenderness. J.H. had no pre-existing health issues, but did have surgery on her left knee in 1999. She experienced no issues with infertility and did receive childbirth education. She attended a childbirth education class, a breast feeding seminar, a class on comfort strategies during the birthing process, and also a class on newborn care.

J.H.’s labor lasted for about 20 hours with spontaneous rupture of clear membranes occurring about 22 hours before delivery. She received an epideral for delivery through cesarean section due to failure to progress. Her husband was present during labor and when delivery occurred at 1:29AM on February 25th of 2008. The cesarean section called for a Pfannestiel incision. J.H. delivered an 8 pound, 9 ounce baby boy who interacted mostly with his mother, during the first postpartum hour. This interaction occurred through skin-to-skin contact and an attempt at breast feeding.

Through the postpartum assessment, the following information was found; J.H.’s vital signs were stable with a slight fever demonstrated by a temperature of 37.3 degrees Celsius with her pain rated at a 0 out of 10 for the time being. Her breasts were soft and war, her fundus was firm at her umbilicus, and her foley was patent and draining clear, quantity sufficient, yellow urine. Bowel sounds were faint in all but the left lower quadrant, where sounds were much more prominent. J.H.’s lochia was rubra and moderate in amount while the dressing over her incision was clean, dry and intact. Upon assessment, it was also noted that her lung sounds were clear, and deep tendon reflexes were present on both her left and right lower extremities. She appeared happy to be around her newborn and did not show any variance in her emotions with the company of other people or while alone. J.H. was placed on bed rest for the time being and a clear liquid diet, due to her previous cesarean section. As far as managing her pain was concerned, she had orders for Morphine and Percocet. She also had an IV that was running 1000ml of lactated ringers at 150ml/hr.

Throughout the course of the day, J.H. was given a bed bath due to her inability to mobilize as well as before the surgical procedure. Also, the primary nurse assisted in the initiation of breast feeding through the day, and gave J.H. nipple shields. The primary nurse had recognized that the infant was having some difficulty latching on, and J.H. seemed somewhat unsure of herself and performing the technique. The nurse had provided J.H. with the nipple shields in hopes of easing the breast feeding process until a lactation consultant was available to meet with her.

Nursing Diagnoses
The following nursing diagnoses have been developed for J.H. in relation to her current health status:
1. Risk for infection related to surgical procedure as manifested by abdominal surgical incision
2. Risk for acute pain related to recent surgery as manifested by abdominal incision
3. Impaired physical mobility related to recent surgery as manifested by decreased ability to move self
4. Activity intolerance related to anesthetic administration, surgical incision and pain as manifested by inability to move self
5. Impaired bed mobility related to acute pain as manifested by the decreased ability to move self in bed
6. Impaired skin integrity related to surgical incision and temporary bed rest as manifested by being immobile
7. Risk for constipation related to the use of opiates to relieve pain as manifested by faint bowel sounds
8. Knowledge deficit related to breast feeding procedure and techniques as manifested by asking many questions and showing little confidence in completing the task
9. Risk for ineffective breast feeding related to being a first time mother as manifested by difficulty assisting baby in latching on and staying latched on
10. Risk for disturbed sleep patterns related to breast feeding as manifested by waking often to feed the infant.

Risk for infection was determined to be top priority in caring for J.H. because it brought about the biggest risk to her health. Pain was second because it is very important to be sure that patients are comfortable and are not experiencing any discomfort. If pain is tended to, then mobility both in and out of the bed, can be greatly enhanced. If J.H. were to experience pain, she would be much less likely to attempt to become mobile, which is why mobility was placed as the third and fourth diagnoses. With impaired mobility, then comes other risks such as poor skin integrity, and the possibility of constipation, because the patient is immobile. If in bed for too long, J.H. could experience skin breakdown and a possible bowel obstruction. Ineffective breast feeding and disturbed sleep pattern were placed as the last diagnoses because although they are important, they rank as the least likely to cause a serious issue with the mother’s health. These diagnoses were also ranked based on the ways in which they would be approached. This meaning that if one diagnosis is tended to, then it is likely that there will not be an issue with the following diagnosis.

Risk for Infection
Assessment
Through assessment, the following information was gathered in relation to this diagnosis.
Subjective Information:
-J.H. states that she does not feel as though she is ill
-J.H. is aware that she has an abdominal incision
-J.H. understands the need to keep the incision covered for the time being with a sterile dressing
-J.H. asks whether or not the dressing over her incision is clean and dry
-J.H. is curious about how to keep the incision clean once the dressing comes off, in order to prevent infection from occurring

Objective Information:
-Temperature of 37.3 degrees Celsius
-Pulse of 80 beats per minute
-Respiration rate of 16 breaths per minute
-Blood pressure reading of 122/59
-Dressing is clean, dry and intact
-Incision is slightly red without any signs of edema, ecchymosis, or discharge, and the edges of the wound are well approximated
-Staples in the incision are still in place
-J.H. shows interest in caring for her incision
- Lab values were shown to be within normal parameters

Goals
Short Term Goal:
As a short term goal, the patient will be able to state ways in which she can decrease the risk for infection. This goal will be measured by listening to the patient restate the topics that have been discussed with her regarding infection prevention. She must be accurate in what she restates and show that she understands what she has been taught. The patient will be able to meet this goal by noon. By this time, the necessary interventions will have been implemented, and evaluation can be completed.

Long Term Goal:
A long term goal for J.H. is that she will not develop an infection. This goal can be measured with the use of a thermometer to determine whether or not a patient is running a fever, the assessment of lab results, paying particular attention to white blood cell counts, and the physical assessment of the incision site. This goal should be met within three days, after the incision has been closed. This also being around the time when the patient is to be discharged.

Nursing Interventions:
1. Intervention: Assess the patient’s abdominal incision and dressing
Rationale: Allows the nurse to recognize indications of healing which are: no redness, edema, ecchymosis or drainage, the edges of the wound are well approximated, the dressing is clean, dry and intact, and that the abdomen is soft (Melson 103)
Outcome: Patient's abdominal incision will be clean, dry and intact, while the incision will exhibit no signs of infection
2. Intervention: Monitor vital signs every 4 hours, or as needed
Rationale: Provides a baseline that allows for rapid recognition of abnormal values (Newfield 54)
Outcome: Patient's vital signs will remain stable
3. Intervention: Use standard precautions
Rationale: Protecting the patient from infection (Newfield 54)
Outcome: Standard precautions will be used at all times necessary
4. Intervention: Educate the patient on eating nutritiously
Rationale: There are strong links between good nutrition and the prevention of certain infections and diseases, nutrition also plays one of the biggest roles in a woman’s health throughout all stages of her life (Newfield 56)
Outcome: Patient will be able to tolerate a nutritious diet full of all the necessities to assist her in maintaining and promoting good health
5. Intervention: Teach the patient and her significant other how to use aseptic techniques in caring for the incision through hand washing and wearing gloves
Rationale: These measures will greatly decrease the risk of introducing additional organisms into the wound (Swearingen 704)
Outcome: The patient and her significant other will be able to decrease the risk of infection through handwashing and wearing gloves
6. Intervention: Teach the patient how to monitor her abdominal surgical site for signs of infection which would include: redness surrounding the incision, the abdomen being warm to touch, and any drainage from the incision
Rationale: A knowledgeable patient is likely to report infection indicators promptly which in turn will reduce the risk of maternal morbidity, possible hospitalization, and the length of treatment (Swearingen 704)
Outcome: The patient will be able to recognize signs and symptoms of infection

Outcome
The interventions provided in an attempt to treat the nursing diagnosis, gave a positive outcome. The patient was open to learning and interested in taking care of herself so that she would not catch an infection. She voiced that she was comfortable in caring for her incision, as did her husband, who was also present for the teaching. Upon assessment, the incision looked well approximated, was not red or swollen, and had no drainage. J.H.’s vital signs remained stable and all within parameters. J.H. appears to be much more relaxed in the idea of caring for herself and her wound after having gained knowledge on how to do so.

Evaluation
Shortly after having taught J.H. about caring for her surgical incision in order to prevent infection, an evaluation of the intervention was done. J.H. was asked to repeat the information that she was given in order to ensure that she had heard correctly, and had a clear understanding. In order for this goal to be met, J.H. had to be able to repeat correct, relevant information in caring for her wound to prevent infection. J.H. was able to do so. In speaking to J.H. about her incision and ways to care for it, she was more susceptible to gaining the knowledge she needed than she would have if she had been given a pamphlet. It was also in feeding back the information that J.H. was able to retain what she needed to know, and show that she was capable of completing the tasks at hand. Perhaps in giving J.H. information on caring for her incision, and preventing infection, the nurse also could have provided her with written information. With both the written and verbal information on hand, it could be likely that J.H. would have learned more and in the long run, remembered more.

The long term goal was that J.H. would not develop an infection. To determine the outcome of the interventions provided, a longer period between intervening and evaluating is necessary. As far as measuring the outcome is considered, evaluation of this goal is set for February 28th, 2008, at the time the patient is to be discharged. The patient has made some progress towards this goal by showing no signs of infection within the first 12 hours post-op.

Acute Pain
Assessment
Through assessment, the following information was gathered in relation to this diagnosis.
Subjective Information:
-J.H. states that she has some pain when moving around in bed
-J.H. otherwise states that her pain is a 0 out of 10
-J.H. states that her husband has been assisting her in getting the baby
-J.H. states that her husband has also been assisting in positioning the baby for feeding
-J.H. looks as though she is not experiencing any pain
-J.H. is aware that when and if she feels the need for pain medications because her pain level has risen, she is able to call the nurse

Objective Information:
-A heart rate of 80 beats per minute
-A respiration rate of 16 breaths per minute
-J.H. exhibits no physical signs of distress
-J.H.’s husband is picking up the baby and giving him to J.H. so that she does not need to move around so much
-J.H.’s husband is also asking her if she is comfortable and if she needs anything
-J.H. also appears to be resting comfortably in her bed.

Goals
Short Term Goal:
A short term goal to have J.H. meet in terms of pain control is that the patient will be able to demonstrate the use of relaxation techniques in order to prevent or control pain. The tool that will be used to determine whether or not this goal has been met, will be the patient’s ability to show what makes for a relaxing environment, and how to calm herself down so that she is relaxed. The evaluation of this goal should occur by at least noon, or after lunchtime.

Long Term Goal:
A very important long term goal for J.H. would be that the patient does not experience or report pain. Upon evaluating this goal, the pain scale will be used as a tool to determine the level of J.H.’s pain, and will be assessed around 3:00PM. By this time, J.H. should have been able to use her relaxation technique to lessen or remove any pain she had been experiencing.

Nursing Interventions:
1. Intervention: Assess pain at least every two hours, on a scale of 0 to 10 including location of pain, severity, duration, and defining characteristics
Rationale: Allows nurse to confirm that the pain is related to the abdominal surgical incision (Melson 97)
Outcome: Patient will experience no pain
2. Intervention: Assess the patient’s response to the pain medications given
Rationale: Confirms the effectiveness of the pain medications given (Melson 97)
Outcome: Patient will state that the pain medications have reduced her pain level
3. Intervention: Provide the patient with a quiet and calm environment
Rationale: Decreasing stimuli promotes relaxation (Newfield 488)
Outcome: Patient will be able to relax
4. Intervention: Pain medications that are prescribed as needed should be administered before pain becomes severe
Rationale: Prolonged stimulation of pain receptors results in increased sensitivity to painful stimuli, and the need for an increase in the dose of medication is necessary to relieve pain (Swearingen 40)
Outcome: Pain medications will be given at scheduled times to prevent the occurrence or worsening of pain
5. Intervention: Consider planning nursing activities to enable long periods of uninterrupted sleep at night
Rationale: Promoting rest and sleep will in turn will decrease a patient’s level of pain (Swearingen 43)
Outcome: Patient will be able to rest without interruptions
6. Intervention: Consider alternative methods for pain management
Rationale: If alternative methods are provided to a patient, there will be no dependence on pain medications, or the need for a lesser dose of medications to relieve pain (Newfield 488)
Outcome: The patient will be able to use alternative methods to manage pain
7. Intervention: Teach the patient to report any pain as soon as it begins is crucial in pain control
Rationale: Pain is more readily controlled when it is treated early and beginning treatment at the very first sign of pain prevents the patient from experiencing periods of pain relief with alternating periods of severe pain (Newfield 487)
Outcome: The patient will be able to report any pain as soon as it occurs
8. Intervention: Document the effectiveness of the medications given
Rationale: Documenting communicates the level of pain relief, interventions done and the effectiveness of such interventions (Swearingen 43)
Outcome: Records will show that medications have relieved pain

Outcome
J.H. was able to use relaxation methods to decrease her pain and improve her level of comfort. J.H. was receptive to alternative forms of controlling her pain, aside from pharmacological management. J.H. stated that she did find the relaxation methods along with a calm and quiet environment to be useful in lessening her pain. J.H. continued to appear comfortable and did not complain of any pain through out the day, aside from when she moved around in bed. She was open in talking about the pain she did have upon movement and was very descriptive, which made it helpful in determining how to decrease her pain.

Evaluation
The short term goal for J.H. to reach was evaluated around noon. The patient was able to express the ways in which she could promote relaxation and use relaxation techniques in decreasing her pain level. In providing J.H. with an alternative form of controlling her pain, she was in less of a need for pharmacological intervention and when pharmacological intervention was provided, she did not need the maximum dosage. Some additions that could have been made in treating J.H.’s pain include providing other forms of non-pharmacological pain management aside from just relaxation techniques. If she had been provided with more options, perhaps her pain level could have been reduced even more effectively and promptly.

The long term goal was to be evaluated on February 25th, 2008 at 3:00PM. Although pain was planned to be assessed every two hours, it was important to determine whether or not the pain management interventions worked effectively. To determine this, it was concluded that the patient should be evaluated have no pain around 3:00 in the afternoon. The patient had made significant progress towards this goal in showing very little, or no pain at all throughout the course of the day.

Impaired Bed Mobility
Assessment
Through assessment, the following information was gathered in relation to this diagnosis.
Subjective Information:
-J.H. states that she has some difficulty moving around in bed
-J.H. asks her husband to assist her in getting the baby and positioning the baby for feeding
-J.H. states that she is in pain when she tries to move in bed
-J.H. states that she needs assistance in turning

Objective Information:
-J.H. has difficulty rolling onto her side during a bed bath
-J.H. has had a recent abdominal surgery
-J.H. has an abdominal incision
-J.H. has been put on bed rest for the time being because of her recent surgery
-J.H. has difficulty assisting in boosting herself up in the bed



Goals
Short Term Goal:
A short term goal for J.H. is that she will be capable of moving herself freely within the bed. The tool that will be used in measuring the outcome of this goal is simple assessment of a patient’s ability to move about in her bed. At the beginning, the patient had very limited movements and needed assistance so, upon evaluation, the nurse should note that there has been an improvement in the patient’s ability to move in her bed and change positions without any assistance. J.H. should be able to reach this goal by noon on the day of her surgery.

Long Term Goal:
A long term goal for J.H. in regards to her impaired bed mobility is that she will be able to sit on the side of the bed and dangle her legs for a short period of time. This goal will also be evaluated with an assessment of the patient’s ability to move from a semi-fowler’s position into a sitting position on the side of her bed. This goal should be reached by at least 3:00PM on the day of her surgery.

Nursing Interventions:
1. Intervention: Assess a patient’s mobility level
Rationale: Nurse will have a baseline to look at and assess whether or not the patient has made any progress towards her goal (Newfield 305)
Outcome: The nurse will be able to determine the patient's level of mobility
2. Intervention: Determine teaching needs regarding mobility for the client with mobility activities
Rationale: Appropriate planning will increase the likelihood that the patient will be safe and be consistent in her efforts (Newfield 305)
Outcome: The nurse will be able to dertemine specific teaching needs for the patient
3. Intervention: Identify and provide assistive devices, such as a trapeze or even the use of the side rails
Rationale: Facilitate a patient’s mobility in bed (Newfield 305)
Outcome: The nurse will be able to provide and identify useful assitive devices for this patient
4. Intervention: Give the patient the appropriate dose of pain medications prior to activity
Rationale: Lessen a patient’s pain level and in turn, enhance the patient’s mobility in bed (Melson 97)
Outcome: The nurse will administer pain medications at least half and hour prior to activity
5. Intervention: Before rising the patient from her bed, the nurse should assess for dizziness or motor weakness from weak knees or legs
Rationale: Nurse is able to refrain from assisting a patient from sitting up in bed and possible experiencing a fall because that patient cannot sit on her own or may experience orthostatic hypotension (Littleton 639)
Outcome: The nurse will determine that there are no signs of dizziness or signs of motor weakness
6. Intervention: Assist with progressive ambulation beginning with having the patient dangle her legs on the side of the bed and will progress to sitting at the bedside and taking accompanied walks over designated lengths
Rationale: Hypotension and vertigo commonly accompany early ambulation, so it is important to start out small and work upwards (Melson 104)
Outcome: The patient will begin with dangling her legs over the side of the bed and will progress to more involved, longer periods of ambulation
7. Intervention: Provide ongoing documentation regarding assessment of the patient and her tolerance to mobility activities
Rationale: Ensures safety and prevents injury (Newfield 305)
Outcome: Records will show that the patient's mobility status and tolerance are improving

Outcome
J.H. was diligent in her attempts to assist herself in moving in her bed. Rather than giving in because she felt as though she could not succeed, the patient continued to push herself. J.H. was determined to be able to be as independent as possible. She stated that she did not want to rely on the assistance of others for herself, when she had her infant to care for. J.H. made consistent progress in her ability to be mobile in bed. The patient was strong-willed and made every attempt to move on her own without the help of the nurse or her husband. She made use of both the side rails on her bed, and her feet to assist her in moving.

Evaluation
The evaluation of the short term goal for J.H. to meet was evaluated around noon, the same day of her surgery. The progress and completion of this goal was measured with pure assessment of J.H.’s ability to change positions in her bed, without any assistance from the nurse or her husband. Perhaps to improve goal achievement, the nurse could work more with the patient in doing exercises while in bed. These exercises would gradually increase the patient’s strength and in turn enhance her ability to change positions in bed without assistance. Even without such exercises, J.H. was able to achieve the goal of being capable of moving herself freely within her bed.

The long term goal was to be evaluated around 3:00PM on the same day of J.H.’s surgery. The patient has made some progress towards this goal by being able to change positions in her bed without any assistance. The patient had started with being able to hardly assist herself in changing positions and needed the assistance of others to do so. Because she has made this change in her ability to be mobile, it shows that she is making progress to becoming even more mobile than she currently was.

Overall Evaluation
Overall, with the interventions done for each nursing diagnosis given to J.H., the nurse was able to improve the health status of the patient. Even with what appeared to be simple nursing interventions, the patient was taken from her current health status and brought to a much more enhanced state of health. This enhancement will greatly affect the outcomes of the patient’s surgery and new role of becoming a mother. Before interventions were provided, the patient had a deficient knowledge of how to care for her incision in order to decrease her risk for developing an infection, she was somewhat unaware of non-pharmacological ways to decrease her pain level, and she had great difficulty being mobile in bed. After having intervened toward these specific issues, the patient could explain how to care for her incision to prevent infection, she could use relaxation techniques to lessen her pain, and she was able to change positions on her own in her bed.

Conclusion
In conclusion, a thorough nursing care plan can greatly assist in meeting the needs of what appears to be a complicated patient. In developing a nursing care plan, one can clearly organize diagnoses with specific interventions to meet the desired goals to treat the diagnoses. In preparing the care plan, a nurse can aim to care for certain needs of a patient and perform the interventions in an organized manner to achieve the goals being aimed at.



References
Hanson-Smith, B. (1989). Nursing care planning guides for childbearing families. Baltimore: Williams &Wilkins.
Littleton, L., Engebretson, J. (2005). Maternity nursing care. United States: Thomson Delmar Learning.
Melson, K., Jaffe, M., Kenner, C., Arnlung, S. (1999). Maternal-infant care planning. United States: Springhouse Publishing Company.
Newfield, S., Hinz, M., Tilley, D., Sridaromont, K., Maramba, P. (2007). Cox’s clinial applications of nursing diagnosis: Adult, child, women’s, mental health, gerontic, and home health considerations. Philadelphia: F.A. Davis Company.
Swearingen, P. (2008). All-in-one care planning resource: Medical-surgical, pediatric, maternity, & psychiatric nursing care plans. United States: Mosby Inc., an affiliate of Elsevier Inc.