Patient Hx Patient Initials: C.W.

Medical Diagnosis:Pregnancy, Gestational Hypertension, Diabeties melatius.

Age, birth history, previous illnesses/surgeries, etc.

Ms. C.W a 34 year old female pt. Gravida 3 Para 1. C/S on Nov 5th 2012 @ 1913. Baby is a 36 weeks gestation female that is bottle feed.

Pathophysiology Pregnancy Induced Hypertension: The pathophysiology of gestational hypertension is unknown, but in the absence of features of preeclampsia, the maternal and fetal outcomes are usually normal. Gestational hypertension may, however, be a harbinger of chronic hypertension later in life. Diabetes Mellitus: An understanding of the pathophysiology of diabetes rests upon knowledge of the basics of carbohydrate metabolism and insulin action. Following the consumption of food, carbohydrates are broken down into glucose molecules in the gut. Glucose is absorbed into the bloodstream elevating blood glucose levels. This rise in glycemia stimulates the secretion of insulin from the beta cells of the pancreas. Insulin is needed by most cells to allow glucose entry. Insulin binds to specific cellular receptors and facilitates entry of glucose into the cell, which uses the glucose for energy. The increased insulin secretion from the pancreas and the subsequent cellular utilization of glucose results in lowered of blood glucose levels. Lower glucose levels Nursing Assessment: Vital signs, physical assessment Pt has horizontal incision along bikini line that was closed by staples. Light vaginal bleeding, fundus is firm and one finger breath above umbilicus. Pt is urinating, having bowel movements and is passing gas. Slight edema on lower extremities bilaterally. V/S Temp: 98.5 P: 87 R: 18 BP: 143/81. Pt has a history of Diabetes mellitus and hypertension. Blood Type is A poss. Neg hep B and HIV test. Pos for SVB and Cannabis use. Baby tested neg for Hep B and Cannabis

Nursing Diagnosis: Defiicet Knowledge r/t lack of understanding as evidence by pt stating that she did not know that smoking marigunia was bad for the baby. Goal: Patient will be able to process the information and be able to repeat it back to the nurse. Nursing Interventions

Nursing Diagnosis: Risk for Infection r/t abdominal surgery as evidence by the horizontal incision on the patients bikini line that was closed with staples. Goal: Patient will have no
redness or fever along with no edema on incision by the time the staples are removed

Nursing Diagnosis Acute Pain r/t abdominal incision as evidence by patient stating pain is 4/10.

Goal: Reduce pt pain until it is tolerable in the patients view.

include comfort care, meds, teaching, assessments, etc.

Nursing Interventions

-provide teaching sections on how things that mom takes also effects the baby. - Pace the instructions and keep the sessions short. -encourage the pt to ask as many questions as necessary to facilitate learning. - Encourage repetition of information or new skill. - Provide positive, constructive reinforcement of learning. Incorporate rewards into the learning process.

include comfort care, meds, teaching, assessments, etc. - Assess nutritional

Nursing Interventions

status, including weight, history of weight loss, and serum albumin. Patients with poor nutritional status may be anergic, or unable to muster a cellular immune response to pathogens and are therefore more susceptible to infection. Monitor for signs of infection which include elevated tempature, redness an edema at incision site or prulent drainage at incision site.

include comfort care, meds, teaching, assessments, etc. - administer pain mediation as needed per the mar. - Teach patient to use a pillow and splint the abdominal area when cough sneezing or re adjusting in bed. - Teach pt to keep the abdominal incision clean dry and intact to avoid infection which will cause more pain. - Teach pt to not drive for the first 6 weeks.

Evaluation: Unable to asses

Evaluation: No inflammation or redness noted at the end of my shift. Unable to asses if long term goal is met.

Evaluation: Pt stated that the pain was tolerable by the end of my shift.