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CCBC NURSING PROGRAM
NURSING CARE PLAN ASSESSMENT
Student Name: Heather Geist
Safety Needs:Post op, fall risk 1
Reason for Admission: Uncontrolled gestational diabetes
Diagnosis: Gestational Diabetes
Description of Surgery: C section birth is performed via surgical incision into this uterine cavity to give birth to an infant. Skin incision low transverse incision to expose uterus. Low transverse incision into uterine corpus to remove the baby.
IV:20g L wrist LRS
Patient Care Orders:Foley care, D/C foley, Pulse ox monitor for 24 hrs post op
Occupation:Home care nurse
Family/SO: Married/ Husband
Discharge Considerations: Incision care, Not lifting anything for 6 weeks, Nothing inserted into vagina for 6 wks.
Pathophysiology of Diagnosis:
Gestational Diabetes develops during pregnancy. They have a higher risk of delivering via c section. Most women have normal blood glucose readings after giving birth. The babies are at high risk of being large for gestational age. Having GDM creates a higher risk for perinatal morbidity and mortality. Many women with time develop type 2 diabetes. Pregnant women with diabetes need to increase her caloric intake by 300 kcal/day.
History of Present Illness:
Due date is November 2, 2016
Pre pregnant weight- 280 lbs
Term weight- 320 lbs
Baby is a female
She is breast feeding
Socioeconomic & Cultural Data:
Pt lives with her husband. She does have support from her mother. Does not smoke or abuse alcohol.
(drug, dose, route, & scheduled times)
Diphenhydramine (50mg/ml) PO BID
Insulin Lipro Sliding scale
Lanolin topical oint apply q 3hr PRN
Meperidine 50mg PO For pain (4-7) PRN
Nalbuphine 10mg SQ q 4 hr for pruitis PRN
Naloxone 0.4mg IV once for RR <8/min
Ondansetron 4mg IV q 4 hr PRN
No previous deliveries
Growth & Development
(patient needs & alternations due to illness)
(inspection, percussion, palpation, & auscultation – briefly describe your findings)
Conflict: Intimacy vs Isolation
Analysis: I believe the patient is leaning towards intimacy, she allowed her husband to help and encouraged him to spend the night with her. Patient also stated she liked her husband being there with her.
Hep B (-)
BG 0900 134
General Survey:Sleeping in her bed 0700
Vital Signs:0700 96.9, 72, 18, 117/72, 98% room air. 1200 98.9, 80,16, 118/74, 95% room air
Cardiac/Vascular:+2 edema bilaterally in ankle/ foot. Apical pulse is regular
Respiratory:All lung fields are clear
Gastrointestinal:Full liquid diet. Not passing flatulence. Active bowel sounds in all 4 quadrants
Genitourinary: Fundus is firm and 1cm below umbilicus. Light lochia rubra, Removed foley at 1130, has not bee able to void since being removed
Skin/Wound: Incision is dry and clean. Staples are intact.
Pain:Pt denied pain at 0700, pain of 5/10 at 1000. Gave Meperidine 50mg at 1015
IV/Access: Left carpal 20g. Hung LRS at 0830
Other: Pt denies pain in breasts. No cracked nipples
Ackley, Betty J., and Gail B. Ladwig. Nursing Diagnosis Handbook: An Evidence-based Guide to Planning Care. Maryland Heights, MO: Elsevier, 2014. Print.
Ladewig, Patricia W., Marcia L. London, and Michele R. Davidson. Contemporary Maternal-newborn Nursing Care. Upper Saddle River, NJ: Pearson Prentice Hall, 2006. Print.
Potter, Patricia Ann, Anne Griffin Perry, Amy Hall, and Patricia A. Stockert.Fundamentals of Nursing. N.p.: n.p., n.d. Print.
Lewis, Sharon Mantik, Shannon Ruff Dirksen, Margaret M. Heitkemper, Linda Bucher, and Mariann Harding. Medical-surgical Nursing: Assessment and Management of Clinical Problems. N.p.: n.p., n.d. Print.
New 8/14: S.G.Student Name: Heather Geist
Lewis, Sharon Mantik, Shannon Ruff Dirksen, Margaret M. Heitkemper, Linda Bucher, and Mariann Harding. Medical-surgical