Ob Care Plan

Topics: Childbirth, Systemic lupus erythematosus, Lupus erythematosus Pages: 5 (1062 words) Published: July 12, 2013
Molly Johnson
Nursing 211 Care Plan
Ron B

|Problem | | | |G.B. is an intelligent, confident, 5 feet and 4 inches tall, 28-year-old Caucasian female patient: G1P1, LMP is October 10th, 2012, | |EDC is June 24, 2013 and gestation of 396/7 weeks confirmed by an ultrasound per chart, blood type: B+. Pre-pregnancy weight was 137| |lbs and pregnancy weight is 174 lbs for a total gain of 37 pounds. G.B. stated she eats a “semi-strict vegetarian diet” (no dairy, | |no red meat), rarely drinks alcohol (no alcohol while pregnant), and she has never smoked cigarettes or taken recreational drugs. | |Prenatal labs are negative. G.B. was admitted to hospital after an attempted home birth via midwife assistance with intact membranes| |at 0710 hrs on June 22, 2013. The patient stated her cervix dilated to “only 3 cm after laboring over 24 hours at home”. G.B. stated| |she prepared for labor and delivery by learning the Bradley method and she hired a doula for the postpartum period. G.B. plans on | |breastfeeding her neonate for at least 1 year. She is allergic to penicillin, amoxicillin, and erythromycin. Significant medical | |history includes systemic lupus erythematosus (SLE), past positive PPD and negative xray within last 5 years, and adenomyosis | |(endometriosis interna) via laparoscopy in 2009 per chart. No significant family medical history. G.B.’s supportive, caring, and | |protective husband was at bedside throughout the labor and delivery and postpartum. |

|Assessment and Diagnosis | | | |Diagnosis: Pain R/T delivery AMB grimacing upon palpation and pt statement. | | | |Assessment: Postpartum 3/10 - mild pain prior to pain meds | | | |Diagnosis: Fluid volume deficit R/T Inadequate fluid intake and IV refusal AMB Concentrated urine | | | |Assessment: 450 mL dark yellow urine with strong odor. | | | |Diagnosis: Inadequate oxygenation/perfusion R/T blood loss AMB low SpO2 extended cap refill times and H&H. | | | |Assessment: SpO2 88% on RA. Cap refill >3 sec. H&H= HCT 32.5; HGB 10.8 | | | |Diagnosis: Disturbed Auditory Sensory Perception R/T to physiological stress from labor and delivery and SLE AMB dizziness and | |“whistling, ringing and...

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