Medical Diagnosis at Admission:
Hx Uterine septum repair, Non-reassuring fetal status, variable deceleration's, chronic HTN with superimposed preeclampsia, IUGR, Spontaneous abortion x5, 1D&C.
Current Medical Diagnosis:
C-section for subseptate uterus
Long Term Goal for Client:
Client will remain free from symptoms of infection till discharge fro hospital.
Short Term Goal for Client:
Client will perform activities of recovery or ADLs easily AEB ambulating from end of hall, and back to room, by 1600 of 11-9-14.
Client Developmental Stage:
Client is at the Intimacy vs Isolation stage. Occurring in young adulthood (ages 18 to 40), we begin to share ourselves more intimately with others. We explore relationships leading toward longer term commitments with someone other than a family member. Successful completion of this stage can lead to comfortable relationships and a sense of commitment, safety, and care within a relationship. Avoiding intimacy, fearing commitment and relationships can lead to isolation, loneliness, and sometimes depression. Success in this stage will lead to the virtue of love, (Mcleod, 2008).
Student Learning Objective:
(1) To build competence in assessment of postpartum mom
(2) To perform teaching with postpartum mom
Evaluation of Learning Objective:
(1) SN was able to perform head to assessment on mom with a C-section
(2) SN performed teaching with a postpartum mom, and her spouse.
Legal/Ethical Issue Identified:
Sn observed RN hesitated/Prolonged getting an interpreter for a non-English speaking client, who needed teaching, and pain management.
Student Reflection on Experience:
Client acknowledged SN teaching on Incision care, pain control, infection prevention, breast-feeding, diet, the new father, and care of preterm infant as very informative, and helpful. Client stated understanding, and voiced back teachings to student. Client had intermittent abd incision pain through the day, needing prn pain treatment; SN incorporated some non-pharmacological intervention, which client was willing to try, such as guided imagery, deep breathing exercise. Client stated that she found the deep breathing helpful. Client displayed healthy bounding with her baby, and desired to be close to her baby most of the time.
NURSING CARE PLAN
Nursing student is to complete the form in preparation for administration of medications and to care for client. This is an expandable form that students can use electronically to complete required information.
ASSESSMENT (DATA BASE) INFORMATION: Subjective / Objective Data:
EVIDENCE-BASED DATA FOR SUPPORT:
Client is a 26yr old Caucasian female, admitted for IUP/R/O/preeclampsia. She had a C-section on 11/7/14 for subseptate uterus,Hx Non-Reassuring fetal status, and variable deceleration's with superimposed preeclampsia and IUGR. Client is bounding well with her baby, who is receiving per-term nursing care.
Breast-feeding: Breast general appearance: Smooth, even pigmentation, changes of pregnancy still apparent, soft to palpate, Nipples are pigmented, intact, Wearing support bra.
Fundus is tender to touch, and firm, measuring below the umbilicus.
Client verbalizes pain R/T incision secondary to caesarian, states pain is worse especially after expressing breast milk, she describers the pain as sharp and cramping, intermittent, and debilitating. States “ it hurts so bad”. Noted grimacing, slightly irritable, guarding her incision with a pillow, rate pain a 7/10.
Postoperative pain management is very important not only for patient comfort,38 but also because the mother needs to be comfortable so she can concentrate on her time with the baby and begin the attachment process. Postoperative pain can decrease success at breastfeeding and may reduce mobility,