HOLY FAMILY UNIVERSITY
SCHOOL OF NURSING AND HEALTH SCIENCES
Patient Care Worksheet NURS 431
Patient Initials SD
Room # 3003
Age 27 Sex F
Allergies : NDKA
Weight (kg) 112.3
Medical Diagnosis/History
Admitting Medical Diagnosis:
Cesarian section
Past Medical/Surgical History:
Left Femur fracture.
Tonsilitis
AB+ blood type
G/T/P/A/L
G3, T2, P0, A0, L2
Significant Family History:
Hypertension
Breast cancer on the maternal side.
Student’s Signature: MS
Patient Assessment
Treatments/Procedures/Equipment:
Safety: moderate risk for fall (score 12)
Neuro/Mental Status: AAOx4, with PERRLA within
normal limits, moderate hand grip b/l, gait steady.
Pulmonary: Clear lung sounds in all lobes, no SOB, no
cough, normal respiration speed, no dyspnea, SpO2 is
100% on 4L/min oxygen
Cardiac: Regular apical pulse, +1 peripheral edema,
capillary refill < 3seconds in upper and lower extremities.
Abdominal/G.I.: soft, non-tender, bowel sounds present
in all 4 quadrants.
Fundus: Fundus is at the umbilical level, firm and
midline.
Lochia: moderate rubra lochia, with pads changes every
2 hours.
Skin/Incision: normal color, texture and turgor
Incision does not present any redness, swelling, or
discharge.
Nutrition/Diet: patient is on clear liquid diet.
Intravenous Therapy: no IV present.
G.U./I&O/Foley: Foley removed at 0830
Patient’s 1st void: 200 mL at 1200
Patient’s 2nd void: 330 mL at 1630 mL
Activity: patient was able to ambulate to the bathroom
and back to the bed with help.
Pain Assessment: Patient reports pain level of 7 on a
scale of 0-10, at the incision site. Patient describes pain as
tightness and sharp with movement.
Significant Social History:
Patient has her mother and husband as support.
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Vital Signs:
Temperature 99.1
Pulse 62
Respirations 22
Blood Pressure 110/82
1
Oxygen: 4L/min
Mini-Nebs: N/A
TEDs/SCDs: N/A
Blood Glucose: N/A
PT/OT Orders: N/A
Psychosocial Spiritual/Cultural Concerns:
English speaking with no cultural concerns.
African American race.
Code Status/Advanced Directives:
Full Code
What did you learn taking care of this patient?
I learned that this patient tripped and fell while pregnant
at 38 weeks and 2 days and the doctor performed a Csection due to vaginal bleeding and breached fetus. I was
able to apply the assess the patient in postpartum using
the BUBBLE HEP technique.
Holy Family University School of Nursing and Health Sciences
PATHOPHYSIOLOGY WORKSHEET FOR PRIMARY MEDICAL DIAGNOSIS
Primary Medical Diagnosis (include source):
Secondary Diagnoses:
C-section
Vaginal Bleeding
Etiology of Primary Diagnosis (include source):
Pathophysiology of Primary Diagnosis (include source):
A cesarian birth is the delivery of a fetus through a transabdominal incision of
the uterus to preserve the life and the heath of the patient and her baby when
there is evidence of complications. Incisions are made vertically, or
horizontally on the abdomen, but the horizontally is the preferred one.
Lowdermilk, D. L., Perry, S. E., Cashion, K., Alden, K. R., & Olshansky, E. F.
(2020). Maternity & Women's Health Care. Elsevier.
Clinical Manifestations of Primary Medical Diagnosis:
Textbook Description:
Medical Treatment/Regimen (Textbook):
-Spinal (block) anesthesia
-Epidural (block) anesthesia
Cesarean section is a fetal delivery through an open abdominal
incision(laparotomy) and an incision in the uterus (hysterotomy). To
achieve a cesarean delivery, the surgeon must traverse all the layers that
separate him/her from the fetus.
Lowdermilk, D. L., Perry, S. E., Cashion, K., Alden, K. R., & Olshansky, E. F.
(2020). Maternity & Women's Health Care. Elsevier.
S/S Manifested by your Patient:
- Decreased fetal Heart rate due to trauma
Actual Treatment Ordered:
- preservative-free morphine
- Tylenol
- Incision care
-pain medications
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Diagnostic Data (Lab, etc.)
Lab/Test Name
Group B Strep screening
Date
Lab/Test
Performed
04/30/2023
Negative
Negative
Pt is negative for GBS. No Group B strep infection present.
There is no risk of infection for the fetus.
HIV antibodies screen
04/30/2023
Negative
Negative
Patient it’s negative for infection with HIV. Very low risk of
infection for the fetus.
Hep B antibodies screen
04/30/2023
Negative
Negative
Patient is negative for infection with Hep B virus. Very low risk
of infection for the fetus.
Hep C antibodies screen
04/30/2023
Negative
Negative
Patient is negative for infection with Hep C virus. Very low risk
of infection for the fetus.
Blood Type
04/30/2023
AB+
Pt has AB+ blood, no ABO incompatibility complications
RBC
04/30/2023
3.29 - 4.85
X1012/L
3.31 X1012/L
Patient is within normal limits, but she can become anemic if she
continues losing blood through the vaginal bleeding.
WBC
04/30/2023
6.0–16.0 × 109/L
8.2 x 109/L
Patient is within normal limits. There are no signs of infection.
Hemoglobin
04/30/2023
12.0-16.0 g/dL
12.9 g/dL
Patient is within normal limits. This result can be an indication
of blood loss due to trauma or C-section surgery.
Hematocrit
04/30/2023
36-46 %
38 %
Patient is within normal limits. This result can be an indication
of blood loss due to trauma or C-section surgery.
04/30/2023
150-400
305
Patient is within normal limits. A low platelet result is an
indication of abnormal bleeding.
Platelets
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Normal Range
Result
3
What Do Results Indicate for this Client?
Signs and Symptoms
Medical Dx/ Reason for
Admission/history/Age
Age
27 y
Past Medical History
Left femur fracture.
Tonsilitis
Reason for Admission
C-section
Objective
Temp: 99.1
Respiration rate:22
Pulse: 62
Pulse Ox: 100% on 4L/min oxygen
BP: 108/82
RBC: 3.31
Hemoglobin: 12.9
Hematocrit: 38%
WBC: 8.2
PLT: 305
Subjective
Abdominal pain of 9 on a scale from 0-10. Patient
describes the pain excruciating in the abdominal area.
Nursing Diagnosis
Risk for deficient fluid volume r/t trauma
induced hemorrhage AEB excessive vaginal
bleeding.
Outcomes
Short Term Goal
Patient will display normal vital signs by the end
of the shift.
Long Term Goal
Patient will remain hemodynamic stable by
discharge.
Evaluation
Was short-term goal met?
Yes, patient maintained vital signs within normal
limits.
Was long-term goal met?
Still in progress.
Nursing Interventions/ Rationales
Nursing Interventions
Assess:
Assess RR, BP, and pulse before, during, and after surgery.
Assess Oxygen saturation level.
Assess Fetal Heart Rate
Rationales for Nursing Interventions
Assess:
A minimal but continued change in vital signs is a sign of impeding hemorrhage.
Oxygen deficits are manifested first by changes in mental status, later by cyanosis.
A decrease in fetal heart rate shows a distress of the fetus.
Do:
Place a towel or wedge under the client’s hip
Place an IV
Administer supplemental oxygen via a mask, as indicated.
Do:
Placing a towel wedge shifts the uterus off the inferior vena cava and increases venous return.
IV access is very important to be able to administer medications and blood products.
Oxygen administration increases the oxygen available for maternal and fetal uptake.
Teach:
Teach the patient that she will have an incision.
Teach the patient to not lift anything heavy
Teach the patient to not drive until cleared by the doctor
Teach:
Teach the patient how to take care of the incision to avoid infections.
Teach the patient that she should not lift anything heavier than her baby.
patient should be helped by her support system until she’s cleared by the physician.
References:
Subasinghe, K. R. L. (2022, September 9). 10 cesarean birth (C-section) nursing care plans. Nurseslabs. Retrieved April 29, 2023, from https://nurseslabs.com/cesarean-birth-nursing-careplans/.
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1/3/23 DM/CT
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Holy Family University
School of Nursing and Allied Health Professions
Medication List
Side Effects
Nursing
Considerations
Generic & Brand
Name
Classification
Acetaminophen
(Tylenol)
NSAIDs
Dose/Route/Frequency
Action
650mg, PO, Q6H (PRN)
Inhibits Cox activity,
blocking pain,
impulses,
peripherally, through
prostaglandin
synthesis, inhibition
Constipation
Dizziness
Diarrhea
Headache
Itchiness
Fatigue
Nausea
Preservative free
morphine
0.2-1 mg as a continuous
Intrathecally
administration
Binds with and
activates opioid
receptors in the brain
and spinal cord to
produce analgesia and
euphoria.
Agitation
Confusion
Dizziness
Increased ICP
Seizures
Lower blood pressure
Bradycardia
Leukopenia
Thrombocytopenia
Apnea
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Patient Education
Reason your client is
taking this medication
Caution used in
hepatic or renal
impaired patients.
Do not exceed
maximum dose daily
Treatment for mild to
moderate pain
postpartum.
Know the chronic
maternal use of
morphine during
pregnancy
Teach the patient to
change the position
slowly due to
orthostatic
hypotension induced
by morphine.
Severe pain during Csection.
Use extreme caution
when administering
morphine to patients
with hypoxia or
decrease respiratory
reserve.
Each the patient that
she will have a PCA
after C-section and
how to use it.
NURSES NOTES
Patient was admitted for emergency cesarean section at 37.5 weeks. The patient is 27 years old, Temp: 99.1, Respiration rate:22, Pulse: 62, Pulse Ox: 100% on 4L/min oxygen,
BP: 108/82 and the fetal heart rate was steady 150. Patient has a history of tonsillitis and left femur fracture. Skin is dry and warm to the touch. Patient states her pain is 9 out of 10
describing it as excruciating abdominal pain. Presently the patient has a Foley inserted with no signs of infection. An IV was placed at 2210 with good return.
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