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OB concept map Female Newborn

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Emily Sawdon

on 11 February 2015

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Transcript of OB concept map Female Newborn

Female
26
Active Labor/ Childbirth

LABS:
Concurrent medical Hx
Subjective Data:
Objective Data:
Nursing Dx:
Outcomes:
Evaluation:
Interventions:
Discharge Planning:
Medications:
ways to help resolve etiology
Results in
Leads to
Leads to
Leads to
Ways to resolve
Resolve or Revise
Lead you to develop
*1. Risk for infection related to cesarean section.

2. Risk for impaired urinary elimination related to childbirth

3. Risk for pain related to cesarean incision
1. Client will demonstarte no signs of infection upon discharge.

2. Client will identify interventions (e.g. proper hand washing & wound cleansing to prevent or reduce the risk for infection once a day prior to discharge.

3. Client will list signs of infection (drainage, redness, swelling, fever etc.) she will report to her HCP upon discharge.
1. Outcome met, client demonstrated no signs of infection (i.e. afebrile, normal range of WBC's for postpartum client upon discharge.

2. Outcome met, client identified interventions (proper nutrition, hand hygiene, keeping incision clean) and did a return demonstration of proper hand washing prior to discharge.

3. Outcome met, client taught back signs of infection (drainage, bleeding, swelling, itching) to watch for to the RN that she should report to her HCP prior to her discharge.
1a. The nurse will assess clients vital signs every four hours. R: Temperature above 100.4 degrees F or tachycardia suggest infection (Murray p750)
1b. The nurse will emphasize and teach the client the necessity of taking antivirals or antibiotics as directed if indicated. R: premature discontinuation of treatment when the client begins to feel well may result in return infection or secondary infection. (Davis p452)
1c. The nurse will administer prophylactic antibiotics or immunizations as indicated. R: infection prevention (Davis p452)
1d. The nurse will change the surgical dressing as needed or indicated when soiled using proper sterile technique. R: this prevents the growth of bacteria (Davis p453)

2a. The nurse will observe the surgical incision for redness, tenderness, edema, and drainage. R: Redness, pain, or edema of incision suggests wound infection. (Murray p750)
2b. The nurse will instruct the client in hygienic practices to prevent infection (i.e. proper hand washing with antibacterial soap, proper incision cleansing). R: good hygiene prevents infection.
2c. The nurse will provide for isolation as indicated (e.g. wound/skin reserve), and educate staff in infection control procedures. R:reduces the risk of cross contamination (Davis p452)
2d. The nurse will offer and encourage client to eat a well balanced meal, and emphasize the importance of high protein and vitamin C. R: adequate protein and vitamin C is necessary for healing. (Murray p750)

3a. The nurse will include information in preop teaching about ways to reduce potential post cesarean infection (e.g. wound and dressing care, avoid others with infection). R:knowledge of risk factors contributing to infection can reduce exposure to known infections.
3b. The nurse will help the client maintain adequate hydration and electrolyte balance. R: this prevents imbalances that may predispose to infection. (Davis p452)
3c. The nurse will review individual nutritional needs, appropriate excercise program and the need for rest. R: this enhaces the immune system functioning and healing
3d. The nurse will monitor the clients WBC count and note any abnormal increases. R: rising WBC count indicated the bodys effort to combat infection (Davis p452)
A:Client is ready to be discharged.
M: Metoclopramide,Oxytocin, Torodol, Acetaminophen, Zipoderm, Benadryl
E: Home will have spouse, safe, heated, running water
T: none
H: Ct taught about infection prevetion
O: Follow up with OBGYN in 6 weeks
D: Diet regular as tolerated
VS: T-97.7, P-66, R- 18 Strong, regular rhythm, B/P-103/59
-Negative Homan's Sign
-Extremities warm with no edema
-Incision dry and intact
-Breath sounds equal and non labored
-Client states she has a pain level of 3, but does not want medication.
-Stated she took prenatal vitamins and had routine prenatal care
-Reports no insomnia. States she rests when the baby does.
-States her incision doesn't hinder her much to ambulate
WBC- 99
RBC- 3.41
HgB- 9.8
HCT- 29.7
Platelet- 200,000
MCHC- 32.9
-Gestational Diabetes

Metoclopramide, Oxytocin, Torodol, Acetaminophen, Zipoderm, Benadry.
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