Professional Documents
Culture Documents
Care Plan
Relavant finds: bubble hear acronym
History of present illness
Admitting diagnosis: Gravida/ Para, time she got here,
- why did the hospital keep her. Could be ruptured membranes,
cervical dilatation of 4 or more, could be induction, repeate c
section
- IUP: induction of labor
- human sign, edema, rhogam, emotions, vital signs
hx of present illness: if patient is in active labor give example how we
know. Cervix is dialted.
Relavant diagnostic tests: ultrasound, hysterosalpingogram
Past medical history: gestational diabetes,
Pertinent lab tests: CBC, AST ALT, 24 hour urine, H/H,
Eriksons: Intimacy and Isolation. Not all patients will be intimate
- explain in her culture what is normal
- no support system
- no money
- no father
interprofessional consults: nutritionist, social workers,
discharge referrals - pediatrician follow up, Ob follow up 6 weeks
after delivery
Potential health deviations: at risk for infection RELATED to uterine
incision secondary to tachycardia, increased respirations, increased
temp.
Independent interventions:
Actual diagnosis: infection as evidence by increased temp, swelling
- fatigue as evidence by inability to keep eyes open.
Planning goals/evaluation: infection teach about hand hygiene;
Medications: relavent side effects related to the patient
- stool softener for patient needs because anemia causes
constipation, patient doesnt want to strain with sore
perineum.
o Nursing considerations
- Oxytocin is givin in micro drips to induce but run fast post
partum