NURSING 110 CARE PREPARATION
Student Name:
Stephanie Perkins
Unit/Room Number: 214
Age: 31
Gender: Female
Erikson’s Developmental Level: Intimacy vs. Isolation
Date of Care:
1/15/15
Date of Admission: 1/14/15
Ethnic/Cultural Preferences:
Allergies: Latex
Code Status: Full
Primary Diagnosis:
Large gestational age caesarian
Co-morbidities:
Obesity, previous caesarian
Discharge Plan (add day of clinical):
Go home with baby to father and babies siblings
Pathophysiology (explain in 250 words or less your clients primary diagnosis)
A caesarian is the surgical procedure of delivering a baby. The reason for this caesarian was due to the baby
being a large gestational age.
Data Collection (Record exactly what is written on the personal information sheet [aka Kardex]. Any assessment/elaboration
should be made on the assessment sheet):
Diet (Type): Regular
I&O (MD order/Nursing Order/Frequency): Daily
Fall Risk/Safety Precautions (Yes/No): yes due to post
op
Wound Care (Yes/No): yes
Drains (Yes/No, Type): no
Other Tubes:
IV (Fluid type, rate, access type): no
CBG (Yes/No, frequency): no
Activity (What is ordered): assist first time, up ad lib
Oxygen (Yes/No, Delivery method, how much): no
Last BM: 1/14/15 am hard
ASSESSMENTS
(Include Subjective & Objective Data)
Integumentary:
O: Appropriate for race, warm, dry, incision above
pubic symphysis from caesarian with dressing over it.
No areas of redness. Scar on left shin approximately 5
½ inches long.
Head and Neck:
O: Normocephalic, hair clean and pulled back,
conjunctivae pink and moist sclera white, PERRLA 2.
Full ROM in tact.
S: “My neck is a little stiff from lying in bed”
S: “It’s from first grade. Cut it on glass. Never got
stitches.”
Ear/Nose/Throat:
O: Ears intact, cecum visible in L ear. No complaints of
drainage or congestion of nose. Nares patent able to
distinguish smells. Mucous membranes intact pink and
moist. Teeth and tongue intact. Able to swallow and
say “ah”.
Thorax/Lungs:
Lung sounds clear throughout. No tactile fremitus.
Respirations easy and regular bilaterally.
S:
S:
Cardiac:
No reports of chest pain, S1 and S2 heard, no edema
present cap refill less than 2 sec, no clubbing.
S:
Musculoskeletal:
Pain of 2/10 grips strong full ROM except ability to
bend at waist is altered due to surgery. Wears scuds
when in bed. Ambulates to bathroom independently.
Ambulated down hallway to nursery and back without
assistance or complaints of SOB.
S:
Genitourinary:
O: Voiding independently, yellow, no odor. Blood
present voided 325 ml
Gastrointestinal:
Obese, last BM 1/14/15 in am abdomen distended
from fundus, fundus at -1 from umbilicus, firm.
S:
S: Pt winced with fundus massage
Neurological:
A/O x 3 GCS 15
S:
Other (Include vital signs, weight):
BP: 94/62
HR: 83
RR: 16
O2: 97
T: 98
Pain: 2/10
CURRENT MEDICATIONS
List ALL regularly scheduled and prn medications scheduled on your client.
(Due morning of clinical)
Generic & Trade
Name
Classification
Dose/Route/
Rate if IV
Onset/Peak
Intended
Action/Therapeutic use.
Why is this client taking
med?
Adverse reactions (1
major side effect)
Nursing Implications for this client. (No more than
one)
Docusate
Sodium
(Colace)
Stool
Softener
100 mg Po
BID
Unknown
Prevent
constipation
Diarrhea
Assess abdomen
Ferrous
Gluconate
(Ferate)
Iron
Preparatio
n
324 mg PO
daily
Unknown
Treat iron
deficiency
Black stool
Assess RBC count
Ibuprofen
(motrin)
Analgesic
600 mg PO
q6h
1h/ 1-2 h
Relief mild to
moderate pain
Nausea
Assess pain level
Bisacodyl
(dulcolax)
Stimulant
Laxative
6-8
h/unknown
Temp relief of
acute constipation
Mild cramping
Assess abdomen
Diphenhydr
amine
(Benadryl)
Antihistam
ine
10 mg 1
supp rectal
prn
25 mg PO
q8h prn
itching
15-30
min/1-4 h
Temp relief various
allergic reactions
Drowsiness
Assess for allergy relief
Hydrocodon
e/APAP
(Norco)
Analgesic
10-20
min/3-6 h
Relief of moderate
to severe pain
Constipation
Assess abdomen
Hydrocodon
e/APAP
(Norco)
Analgesic
10/325 1
tab PO q4h
prn
moderate
pain
10/325 2
tab PO q4h
prn
moderate
pain
10-20
min/36 h
Relief of moderate
to severe pain
Constipation
Assess pain
Magnesium
Hydroxide
(milk of
Mag)
Laxative
30 ml PO HS
PRN
constipation
Unknown
Short term
treatment of
constipation
Diarrhea
Assess for diarrhea
Methylergo
novine
(Methergin
e)
Oxytocic
0.2 mg PO
q6h prn
heavy
bleeding
max 3 doses
5-15 m/
unknown
Control bleeding
Drowsiness
Assess bleeding
DIAGNOSTIC TESTING
Include pertinent labs [ABGs, INRs, cultures, etc] & other diagnostic reports [X-rays, CT, MRI, U/S, etc.]
NOTE: Adult values indicated. If client is newborn or elder, normal value range may be different.
Date
Lab Test
Normal Values
Sodium
135 – 145 mEq/L
Potassium
3.5 – 5.0 mEq/L
Chloride
97-107 mEq/L
Co2
23-29 mEq/L
Glucose
75 – 110 mg/dL
BUN
8-21 mg/dL
Creatinine
0.5 – 1.2 mg/dL
Uric Acid Plasma
4.4-7.6 mg/dL
Calcium
8.2-10.2 mg/dL
Phosphorus
2.5-4.5 mg/dL
Total Bilirubin
0.3-1.2 mg/dL
Total Protein
6.0-8.0 gm/dL
Albumin
3.4-4.8gm/dL
Cholesterol
<200-240 mg/dL
Alk Phos
25-142 IU/L
SGOT or AST
10 – 48 IU/L
LDH
70-185 IU/L
CPK
38-174 IU/L
WBC
4.5 – 11.0
RBC
male: 4.7-5.14 x 10
female: 4.2-4.87 x 10
HGB
male: 12.6-17.4 g/dL
female: 11.7-16.1 g/dL
HCT
male: 43-49%
female: 38-44%
MCV
85-95 fL
MCH
28 – 32 Pg
MCHC
33-35 g/dL
RDW
11.6-14.8%
Platelet
150-450
Patient Values/
Date of care
8.2
4.55
13.1
39.5
87
28.8
33.2
13.5
153
Interpretation as related to Pathophysiology –cite
reference & pg #
DIAGNOSTIC TESTING
Date
UA
Normal
Range
Results
Interpretation as related to
Pathophysiology –cite reference & pg #
Results
Interpretation as related to
Pathophysiology –cite reference & pg #
Color/Appearance
pH
Spec Gravity
Protein
Glucose
Ketones
Blood
Date
Other
(PT, PTT, INR, ABG’s,
Cultures, etc)
Date
Radiology
X-Rays
Scans
EKG-12 lead
Telemetry
Normal
Range
Results
Interpretation as related to
Pathophysiology –cite reference & pg #
DAR NURSING PROGRESS NOTE
Include the same note that was written in the client record for the priority nursing diagnostic statement.
Include the date/time/signature.
1/15/15 0745
Assumed care A/O x 3 awake and watching TV ate breakfast. Postop caesarian 1/14/15. Massaged fundus. -1
umbilicus. Winced in pain taught breathing technique of blowing out while massaging. Pain meds given see
MAR (Ling RN gave meds). Left patient breastfeeding daughter. Scuds on properly call light and water within
reach. -------------------------------------------------------------------------------------------------------------Stephanie Perkins SN
PATIENT CARE PLAN
Patient Information:
Nursing Diagnosis should include Nanda Nursing Diagnostic statement, related to (R/T), as evidenced by (AEB).
Problem #1 Acute Pain r/t incision site AEB surgical procedure
Desired Outcome: Pain will be at or below a 5 on a scale of 0-10 during shift
Nursing Interventions
Client Response to Intervention
1. Assess pain level every hourly round
1. Stated pain was a 2/10
2. Give ibuprofen or hydrocodone when appropriate
2. Ling RN gave patient ibuprofen
3. Teach relaxation techniques
3. Demonstrated proper breathing out when
massaging the fundus
Evaluation (evaluate goal & interventions, what worked/what didn’t, what would you adapt if needed): I was surprised at how
little pain this patient was in considering she had a c section yesterday. She did wince when we first started massaging the fundus,
but she used good breathing techniques and it seemed to help.
Problem #2 Risk for Injury (DVT) r/t abnormal clotting AEB surgical procedure
Desired Outcome: Patient will no present with a blood clot during shift
Nursing Interventions
Client Response to Intervention
1. Assess LE for edema
1. No edema present
2. Use scuds properly when in bed
2. Scuds were used whenever in bed
3. Reinforce importance of ambulation postop
3. Patient ambulated down hall and to nursery
and back without complaint of pain or SOB
Evaluation: I think this goal worked really well with this patient. She was motivated to get up and moving.
She was able to walk to the shower room and clean up as well as to the nursery and back. By the end of the
shift she was ambulating independently.
Problem #3 Activity Intolerance r/t surgical procedure AEB hospitalization
Desired Outcome: Pt will ambulate 50 ft by end of shift
Nursing Interventions
Client Response to Intervention
1. Assess for pain every hourly round
1. Pt reported 2/10
2. Encourage use of assistive device if necessary for
ambulation
2. Assistive device not needed
3. Teach about regulation of energy to prevent
fatigue
3. unable
Evaluation: Again, I was very surprised at how quickly this pt was able to get back to walking around without
assistance. She was very motivated, however, and I think setting these goals only added fuel to that fire.