Ob Care Plans
Natalie Sullivan 6/4/2013 Nursing Care Plans
Care Plan: Post Partum
Patient’s initials: SR
Date of Care: 5/6/2013
Assessment Data: * G1P1 * C/S on 5/5/2013 at 1832 * Incision at suprapubic region * Staples mid right side to end of left side of incision * Steri strips on right side of incision r/t to removal of 5 staples because staples were loose * Pt complaining of pain in lower abdomen * Pt complaining of “uncomfortableness” at incision site * Scant bleeding at incisional site on steri strip
Nursing diagnosis: risk for fall r/t epidural and anesthesia aeb c/s delivery
Goal: pt will remain free of falls for remainder of clinical shift and stay at hospital
Nursing interventions and rationales: I. Teach client and family about the fall reduction measures that are being used to prevent falls * Prevention begins with education, the more the client and families know about how to prevent falls the more likely they will comply (i.e. leaving 2 head side rails up on clients bed, leaving floor free of clutter) and the safety of the client will be in everyone’s best interest. II. Call light in reach of patient: * Leaving the call light near the patient at all times helps prevent injury by not having the patient get up to reach the call light, it also helps the patient reach the nurse faster when they need help, have a question, or are in need of something. III. Nurse will assist patient to bathroom and when ambulating in room: * Client will need support to ambulate and use restroom when she is ready and anesthesia as worn off, clients legs will be weak and she will be tired and experiencing pain around incisional area and need assistance when using the restroom to prevent falls and injury.
Evaluation:
Goal met, patient remained free of falls while duration of stay. Side rails remained up while patient in bed; patient used call light for help to ambulate to
Care Plan: Post Partum
Patient’s initials: SR
Date of Care: 5/6/2013
Assessment Data: * G1P1 * C/S on 5/5/2013 at 1832 * Incision at suprapubic region * Staples mid right side to end of left side of incision * Steri strips on right side of incision r/t to removal of 5 staples because staples were loose * Pt complaining of pain in lower abdomen * Pt complaining of “uncomfortableness” at incision site * Scant bleeding at incisional site on steri strip
Nursing diagnosis: risk for fall r/t epidural and anesthesia aeb c/s delivery
Goal: pt will remain free of falls for remainder of clinical shift and stay at hospital
Nursing interventions and rationales: I. Teach client and family about the fall reduction measures that are being used to prevent falls * Prevention begins with education, the more the client and families know about how to prevent falls the more likely they will comply (i.e. leaving 2 head side rails up on clients bed, leaving floor free of clutter) and the safety of the client will be in everyone’s best interest. II. Call light in reach of patient: * Leaving the call light near the patient at all times helps prevent injury by not having the patient get up to reach the call light, it also helps the patient reach the nurse faster when they need help, have a question, or are in need of something. III. Nurse will assist patient to bathroom and when ambulating in room: * Client will need support to ambulate and use restroom when she is ready and anesthesia as worn off, clients legs will be weak and she will be tired and experiencing pain around incisional area and need assistance when using the restroom to prevent falls and injury.
Evaluation:
Goal met, patient remained free of falls while duration of stay. Side rails remained up while patient in bed; patient used call light for help to ambulate to
References: Lowedermilk, D., Perry, S., Cushion K., & Alden, K. (2012). Maternity & women’s health care. 10th edition. St. Louis: Elsevier Mosby. Ackley, B.J. & Ladwig, G.B. (2011). Nursing diagnosis handbook: An evidence-based guide to planning care. 9th Edition. St. Louis: Elsvier Mosby.