ASN Nursign Program
Antepartum / Intrapartum / Postpartum
Comprehensive Patient Care Plan
Student Name:
Elizavet Bravo
Course Number: NUR2421C
PATIENT INITIALS: RJ
ALLERGIES: NKDA
AGE:14
ADMISSION DATE &
TIME: 7/22/23 &0030
CLINICAL SITE: North
shore
WEIGHT:145 LB.
Hospital
HEIGHT:5’6”
ROOM/BED: 388
GESTATIONAL AGE:
37 WEEKS + 1 DAY
ESTIMATED DUE DATE:
8-10-2023
BLOOD TYPE:
O (+)
RHOGAM: NO
TIME / DATE
CULTURE / ETHNICITY
RELIGION
CHRISTIAN
PRIMARY LANGUAGE
ENGLISH
MARITAL STATUS
SIGNEL
OCCUPATION
STUDENT
HIGHEST GRADE LEVEL
COMPLETED N/A
PRENATAL RECORDS
YES
DELIVERY: CESAREAN
GIVE REASON FOR CESAREAN
DELIVERY: HSV WITH ACTIVE
TIME / DATE OF
DELIVERY 7/21/2023
1845
ESTIMATED BLOOD
LOSS 400ML
SUPPORT SYSTEM:
AUNT
DIET
REG
ACTIVITY ORDER
ORDER-AMBULATE AS
SAFETY
CALL LIGHT IN REACH
TOLERATED
SIDE RAILS UP
AFRICAN
AMERICAN
LEGIONS
G__1__T__1__P__0__A__0__L_1___
BED IN LOW POSITION
PERSONAL ITEMS IN REACH
BRIEF HEALTH HISTORY:
Pt has no known allergies. Pt received prenatal care and has been taking iron and folic acid supplements. EDC was 8/10/2023. Pt was admitted to
the mother baby unit on 7/21/2023 at 0030. Mother has a history of HSV, Anemia, PIH. She was GBS negative and negative for all other test like
HIV, Rubella, chlamydia but positive with active lesions of HSV.
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ASN Nursign Program – Intrapartum Comprehensive Patient Care Plan
ASSESSMENT:
Vitals: RR:22 HR:78 SPO2 98% Temp: 97.6 BP 135/68
Patient is alert and oriented X4, cheerful. She is in bed relaxed with no complaints of pain. Patient is cooperative with no signs of acute distress.
Chest clear, bilaterally, non-labored respirations. IS in use. Bowel sound present and well hydrated. Voiding without difficulty, amber and clear
urine. Face is symmetric, no weakness or involuntary movement. Conjunctivae clear, sclerae is white, no lesion. Patient skin color appropriate for
her race, warm to touch, turgor good, no lesion: nail bed pink with CMS of 2 sec, no deformities. Beast soft/non tender, filling, secreting colostrum.
Assistance needed for breast feeding. Nipples everted and tender. Bowel sounds are present in all 4 quadrants. Fundus firm. Lochia rubra with
moderate amount. Cesarean section with original dressign on; site is dry and intact with no redness or sign of infection. Homan’s sign is negative.
Genitalia: no lesions, no inflammation or discharge. Rectum: No fissures, hemorrhoids. Genitalia red with active lesions. Needs further assessment
with baby bonding.
Patient has a 22-gauge IV catheter inserted on the Rt. forearm. LR solution infuses at 100ml/hr.
MEDICATIONS / TREATMENTS
MEDICATION NAME
(TRADE & GENERIC NAMES)
INCLUDE DOSAGE, FREQUENCY
/ ROUTE AND SAFE RANGE
Nifedipine
(Procardia XL)
30MG, PO once daily/
Initially, 30 or 60 mg
extended-release tablet PO
once daily, adjusted over 7
to 14 days. Maximum dose
is 120 mg/day.
CLASSIFICATION AND
PRIMARY ACTION OF
MEDICATION
NURSIGN IMPLICATIONS / PRECAUTIONS /
CONTRAINDICATIONS
SIDE EFFECTS / ADVERSE EFFECTS
& INDICATION
Antihypertensives– CNS: dizziness,
antianginals
GI: nausea, diarrhea, constipation, cramps,
.
Calcium channel
blockers



Monitor BP and HR regularly,
Fluid retention
Contraindications: Cardiogenic Shock
Therapeutic class:
Antiulcer drugs

Contraindicated in patients allergic to
prostaglandins.
Safe range
Misoprostol( Cytotec)
Headache, abdominal pain, diarrhea
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ASN Nursign Program – Intrapartum Comprehensive Patient Care Plan
MEDICATION NAME
(TRADE & GENERIC NAMES)
INCLUDE DOSAGE, FREQUENCY
/ ROUTE AND SAFE RANGE
200MCG PO QID
200 mcg PO q.i.d. with
food; if not tolerated,
decrease to 100 mcg PO
q.i.d. Give dosage for
duration of NSAID therapy.
CLASSIFICATION AND
PRIMARY ACTION OF
MEDICATION
NURSIGN IMPLICATIONS / PRECAUTIONS /
CONTRAINDICATIONS
SIDE EFFECTS / ADVERSE EFFECTS
& INDICATION

Pharmacologic
class:
Prostaglandin E1
analogues

Use cautiously in patients with
inflammatory bowel disease or known
CV disease.
Overdose Signs & Symptoms:
Sedation, tremors, seizures, dyspnea,
abdominal pain, fever, diarrhea,
palpitations, hypotension, bradycardia.
Safe to give.
Cefazolin Sodium (Firstgeneration cephalosporin)
2G IV intermediate
Children ages 10 to 17 with
CrCl of 70 mL/minute or
more: 2 g if weight is 50 kg
or more or 1 g if weight is
less than 50 kg IM or IV 30
to 60 minutes before
surgery; then 0.5 to 1 g IM
or IV every 6 to 8 hours for
24 hours
Safe to give.
Therapeutic class:
Antibiotics
Pharmacologic
class: Firstgeneration
cephalosporins
Dizziness
Hypertension
Candidiasis
Drug to drug interactions with estrogen-based
contraceptives
Contraindicated in patients hypersensitive
Overdose Signs & Symptoms: Pain,
inflammation, and phlebitis at injection site;
dizziness, paresthesia, headache, seizures;
elevated creatinine, BUN, liver enzymes, and
bilirubin levels; positive Coombs test;
thrombocytosis, thrombocytopenia,
eosinophilia, leukopenia; prolonged PT.
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ASN Nursign Program – Intrapartum Comprehensive Patient Care Plan
MEDICATION NAME
(TRADE & GENERIC NAMES)
INCLUDE DOSAGE, FREQUENCY
/ ROUTE AND SAFE RANGE
CLASSIFICATION AND
PRIMARY ACTION OF
MEDICATION
SIDE EFFECTS / ADVERSE EFFECTS
NURSIGN IMPLICATIONS / PRECAUTIONS /
CONTRAINDICATIONS
& INDICATION
PERTINENT LABORATORY DATA
PRENATAL LABS
HEMOGLOBIN / HEMATOCRIT # 1 6.9/23.50 @1300 7/22/2023
RPR: NONREACTIVE
HGB / HCT # 2 : 8.3/27.60 @2200 7/22/2023
GBS: NEGATIVE
Hemoglobin and Hematocrits values slightly below normal range
on the first laboratory results obtained after c-section delivery.
TX: ________________
RATIONALE FOR ABNORMAL RESULTS:
RUBELLA: IMMUNE
Expected due to blood lost during c-section delivery, values are not
a concern at this time.
The second lab result shows an increase in H/H because of a onetime infusion of packed red blood cells (PRBCs);
NURSIGN CONSIDERATIONS
-Monitor Hemoglobin and hematocrits levels periodically. Administer blood transfusions (blood products) if needed and
HEPATITIS B: NEGATIVE
HIV: NEGATIVE
RATIONALE FOR ABNORMAL RESULTS: No abnormal labs
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ASN Nursign Program – Intrapartum Comprehensive Patient Care Plan
ordered by physician.
PERTINENT LABORATORY DATA
PERTINENT LABORATORY DATA
LAB TEST #1 Platelets: (150-400* 109/L)
LAB TEST #1 WBC – (5,000-10,000/mm3)
RESULTS: 200,000 within normal range
RESULTS: 6,000/mm3 within normal range
RATIONALE FOR ABNORMAL RESULTS:
RATIONALE FOR ABNORMAL RESULTS:
N/A
N/A
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ASN Nursign Program – Intrapartum Comprehensive Patient Care Plan
INTRAVENOUS SOLUTION #1 RBC
INTRAVENOUS SOLUTION #2
TYPE: packed RBC
TYPE:
D5 LR 1000ml
CC / HR: 175ml/hr.
IV SITE LOCATION 22-gauge IV Rt forearm
CC / HR: 125ml/hr.
GTTS / MIN:
GTTS / MIN:
ADDITIVES:
ADDITIVES:
RATIONAL FOR SOLUTION:
IV SITE LOCATION: 22-gauge IV Rt forearm
Hydration Replace water and electrolyte loss due to surgery.
RATIONAL FOR SOLUTION:
Acute anemia caused by trauma, surgical blood loss
EPIDURAL CATHETER INSERTION SITE: Spinal
REDNESS: no
TENDERNESS: no
DRAINAGE: no
NO PROBLEM IDENTIFIED: No
Postpartum Daily Assessment Flow Sheet
Respiratory System:
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ASN Nursign Program – Intrapartum Comprehensive Patient Care Plan
Assessment Date & Time: 7/23/2023 @0800
Breast:
Soft / non-tender
Filling
Firm
Bra on
Binder on
Ice pack applied
NonBreast feeding
Breast feeding well
Breast feeding
needs assistance
Breast pump given
Nipples:
Everted
Non-tender
Inverted
Cracked
Fundus:
Firm
Boggy
Displaced Right / Left
Lochia:
Rubra
Heavy Amount
Flat
Blister noted
Tender
Massaged
Serosa
Moderate Amount
Alba
Scant Clots
Light Amount
Chest clear bilaterally
Non-labored respirations
Wheezes / Crackles
Tachypnea
Chest Pain
Asthma
Cough
Restlessness
Skin & nail color changes
Incentive spirometer in use
Cold
Cardio-vascular system:
Heart regular / Irregular rate / Rhythm
Positive peripheral pulses
B/P less than 140/90 or no greater than 30/15 rise in prenatal baseline
B/P greater than 140/90 or greater than 30/15 rise from prenatal baseline
Edema resolving
No edema of hands / face
Leg / ankle edema with pitting
Extremely discolored
Edema of hands / face
Varicosities of legs (right / left) (both) Vulva
Negative Homan’s sign
Positive Homan’s sign
Episiotomy / Laceration: None
Intact
Swollen
Hematoma
Sitz Bath initiated with follow up
Cesarean Section:
Original Dressign
On
Off
Re-enforced
Incision Intact
Incision Swollen
Redness noted
Describe:____Clean and intact
Odor:___________________________________________________
Steri Strips
Staples In
Drainage Noted
Staples Out
Light Dressign
Bonding with baby:
Well
Poor
Needs further Assessment
Neurological / Psychosocial:
Oriented X 3
Active range of motion
DTR’s +2
Cheerful
Combative
Depressed
Stiff neck
Back pain
NICU
Clear verbal
Agitated
Lethargic
Gastrointestinal System:
Gravid abdomen
Bowel sounds present
No epigastric pain
Well hydrated
Abdomen soft
Bowel Movements
Epigastric pain - describe ______________________________
Heartburn
Nausea
Vomiting
Diarrhea
Constipation
Absent bowel sounds
Hemorrhoids
Gastrointestinal bleeding
Diabetes type:________________________________
N/G tube Present to suction
Hi Low Intermittent
Renal system / Genitourinary:
Voiding without difficulty
Amber
Clear
Voiding with difficulty
Burning
Straight Cathed x _________________ Foley Catheter
Urgency
Identified UTI present
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ASN Nursign Program – Intrapartum Comprehensive Patient Care Plan
Assessment Data
Subjective / Objective
Nursign Diagnosis
Expected Outcome
Short / Long Term
Nursign Interventions
Rational for
Interventions
Evaluation of Goals
400ml Blood loss
during surgery /
Fatigue
Fluid volume and
electrolyte balance
altered related to
cesarean section as
evidenced by lost of
blood.
Pt will show signs of
stabilized fluid volume
by balanced intake an
output, stable weight,
stable VS and absent
of edema
-Administer D5 LR
1000ml
Lost of blood during
IV SITE LOCATION surgery
22-gauge IV Rt
forearm
CC / HR: 125ml/hr.
-Assess for S/S of
dehydration or volume
overload.
-Monitor lab values
and repost to physician
as indicated.
Goal met
incision due to
cesarean sectio
Risk for infection
related to trauma to
the abdominal wall.
Patient will not
develop an infection
during the postpartum
period
-Administer antibiotics Wond healing due to
-provide education on cesarean section.
symptoms
-Demonstrate wound
care
Goal met
Assessment Data
Subjective / Objective
Nursign Diagnosis
Expected Outcome
Short / Long Term
Nursign Interventions
Rational for
Interventions
Evaluation of Goals
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ASN Nursign Program – Intrapartum Comprehensive Patient Care Plan
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ASN Nursign Program – Intrapartum Comprehensive Patient Care Plan
INITIAL HEAD TO TOE ASSESSMENT:
DATE & TIME: 7/23/2023 @ 1800
NEUROLOGICAL: Patient is alert and oriented x 4, cooperative, with no
signs of distress. Appearance, behavior, and speech are appropriate,
memory intact. Face symmetric, no weakness or involuntary movements.
Conjunctivae clear, sclerae white, no lesions.
MUSCULOSKELETAL: Joints and muscles symmetric; normal spinal
curvature. Full ROM, movements smooth, no crepitus, no tenderness.
Muscle strength – able to maintain flexion against resistance. The deep
tendon reflexes were normal. Graded to +2
Patient is ambulating as tolerated.
Cardiac: BP: 135/68 mmHg left arm, sitting. Consistent with baseline.
HR: 78 bpm and rhythm regular.
Carotid pulses 2+ and = bilaterally.
Positive peripheral pulses. No edema on hands / face.
Negative Homan’s signs.
All pulses present, 2+ bilaterally.
Skin: Warm to touch, no temp, turgor good, incision-clean, dry& intact.;
Nail beds pink with prompt capillary refill less than 3 sec, no clubbing, or
deformities. The patient has a 22-gauge IV catheter inserted on the right
arm. DS Lactated Ringer’s solution infusing at 125 mL/hr. by gravity, IV
Dressing is intact.
Incision clean, dry, and intact, Steri-Strips. Abdominal binder in place.
Temp 97.F tympanic
The IV site no, redness, or signs of infiltration.
Genitourinary: Patient is voiding without difficulty. Voided sufficient
amount 500 ml; amber and clear.
Genitalia: lesions, inflammation or no discharge.
RESPIRATORY: RR: 16 rpm, relaxed and even, chest moving equally.
O2 saturation 98% on room air. Resonant to percussion over the lung
fields.
Breath sounds clear. No adventitious sounds. Incentive spirometer in use
Gastrointestinal: Bowel sounds present in all 4 quadrants. Patient
reports her last bowel movement was yesterday, consistency soft and
brown color. Patient is well hydrated. Abdomen is soft. No bowel
movement after delivery yet.
Rectum: No fissures, hemorrhoids, fistulas, or skin lesions
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ASN Nursign Program – Intrapartum Comprehensive Patient Care Plan
DATE: 7/23/2023
TIME: 0800
NURSES’ NOTES:
0800 Patient is comfortable in bed, pain 2/10 on a 0-10 scale at incision site. Chest is bilaterally moving
equally. Saturating at 98% on room air. Breath sounds clear. Pt is A&O x4, corporation with no signs of
distress. Acting appropriate to age. Skin is expected color for ethnicity without lesion or rashes. CMS 2sec. IV
in left arm with DS LR running at 125ml/hr. IV site no pain, redness, or signs of infiltration. Breast soft and
secreting colostrum. Dressing intact. Bowel sound present in all quadrants. Last bowel movement prior to
cesarian section. Genital: lesion, inflammation with no discharge. Rectum; no fissure, hemorrhoid, fistulas or
skin lesions. Vitals: RR:22 HR:78 SPO2 98% Temp: 97.6 BP 135/68
DATE:7/23/2023
TIME:1200
NURSES’ NOTES:
1200Patient got out of bed to void 500ml. Urine was amber and clear. Pt ambulation as tolerated. Education was
provided to patients regarding activity and fall risk. Pt and aunt verbalized understanding.
Pt ambulated x2 with aunt to prevent pneumonia complication and prevent pressure injury. Educated pt on deep
breathing exercises and the use of IS Q hr. for lung maintenance.
1300 Pt complains of pain in abdomen at C-section sutures site after ambulation. 7/10 on a scale of 0-10. pain
med administered.
1400 reassessment of pt pain at 3/10 on a scale of 0-10. Pt education on contraception and vaccination.
Incision original dressing on, dry no discharge noted, no foul order.
Will continue monitoring patient’s intake and output, laboratory values, bowel movement, incision. All safety
and comfort measures in place, call light within reach. Bed in the lowest position, wheels locked. Frequent
rounds to be done.
1400 Normal Vitals: RR:20 HR:70 SPO2 98% Temp: 97.6 BP 125/68
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ASN Nursign Program – Intrapartum Comprehensive Patient Care Plan
DATE:7/23/2023
TIME:06:30
NURSES’ NOTES:
1800 Pt continues to be stable with no complaints. Normal voiding with no bowel movement.
Observed patient bottle feeding infant. The patient aunt verbalized car seat has been properly installed.
Pt remains in stable condition repost given to oncoming RN further education on baby care needed.
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ASN Nursign Program – Intrapartum Comprehensive Patient Care Plan