Labor and Delivery Care Plan

Name: Section__________ Maternal Infant Nursing LABOR & DELIVERY CLINICALS PRE-CLINICAL ACTIVITES: 1. PATIENT: Since labor is somewhat unpredictable, you will tentatively be assigned to be “on-call for labor” the week before you go. You must therefore prepare for a general rather than specific labor patient. 2. Prepare drug information for the following and include in your Assessment Guide Pitocin (oxytocin) Nubain (nalbuphine) Stadol (butorphanol tartrate) Naropin (ropivacaine) 3. Review the following: Ch. 23 in Davidson, London, and Ladewig (2020) 11th edition (Ch 24 in 10th ed) IV therapy –initiating an IV, hanging a piggyback e.g. Ampicillin 2g IV for first dose, then 1g q 4h till delivery, or Penicillin G 5 million Units for first dose, then 2.3 million Units q 4 h till delivery if mom is Beta strep positive, calculating a mainline drip rate flowing by gravity, and changing rates on the IV pump. Foley catheter insertion procedure using sterile technique. Preoperative and postoperative care Handout on the stages of labor and the patient’s responses 4. Be prepared to provide comfort measures, teaching, and support for your laboring patient and her family EXPECTED CLINICAL ACTIVITIES (see essential clinical skills) 1. 2. 3. 4. 5. 6. Assist the RN to provide appropriate nursing care during the intrapartum period Assess contraction frequency, duration, & intensity, Leopold’s maneuvers, maternal psychological response & fetal well-being (EFM) during labor. Refer to attached pages. Assess newborn’s Apgar score & compare with RNs score, Gather patient information to complete the assessment and individualize the care plan Assist the RN to provide care to mother and baby following birth. Complete a nursing care plan with at least 2 priority nursing diagnoses for your patient POST-CLINICAL ACTIVITIES: Name: Section__________ LABOR & DELIVERY ASSESSMENT GUIDE Student: Date of Care: 09/04/2019 The assessment guide is designed to help the student organize data-gathering only. Individual clients may require additional information not included in this guide. Additional pages may be attached to include all pertinent data for an individual client. General Client Information Marital Status G 1 T Married 1 Pt Age 0 A 0 L Estimated Gestational Age (weeks) 1 20 EDD 41w 3d Blood Type &Rh A+ Group B Beta Strep neg VDRL nonreactive 8/25/2019 by sono or dates? sono Rubella immune Hep B __neg__ Sexually Transmitted Infections none HIV neg Gest. Diabetes screen: date 02/07/19 glucose 85 & screen: date 02/07/19 glucose 124 Allergies codeine, penicillin Current medications Daily prenatal vitamin Client History History of All Prior Pregnancies (include abortions, add pages as needed) Year Sex Weight Health/Surgical history Psychosocial history Prenatal Course Complications none none none Document a thorough client assessment below. Include any pathophysiology r/t pregnancy history e.g. gestational diabetes, preeclampsia, Rh factor incompatibility, hx of STD implications for delivery, etc. Include indication for Induction/Augmentation and Risks/Benefits for mother  and baby. Be sure to cite reference, please.) Patient underwent elective induction because she was past her due date at 41w 3d. The risks of this include a greater chance at having a c-section, which increases recovery time Name: Section__________ as well as possible surgical complications. Labor can be induced by the doctor performing an amniotomy to rupture the amniotic sac using a plastic hook to break the membranes. Hormones can also be given. There is also a risk for infection to both mother and baby. Admission Date/time of admission 03/09/19 at 2230 Support person(s) Spouse, Mother, Sister Reason for admission (in client’s own words) Membranes Intact Contractions: epidural SROM XAROM Time 09/04/19 at 0645 None Date/time contractions began Vaginal Exam: Presentation vertex Dilatation 4 Color clear 09/03/19 at 0100 Effacement 90 Station -1 Drug Information- complete prior to day in labor, please. Use your OLD’s text to support your medication implications in Maternity Nursing. Drug Name Mechanism of Action Usage Generic and Trade Name How does it work? Why is your patient receiving it? Dose/Rate of Infusion Side Effects to watch for Effectiveness for patient Specific Nsg Implications Nalbuphine/Nubain Binds to opiate Severe pain Dizziness, 10 mg q 2 hour PRN receptors in the CNS. headache, sedation, IV Alters the perception confusion, dry of and response to mouth, nausea, painful stimuli while sweating producing generalized Ropivacaine/Naropi CNS depression. Blocks the generation Numbing medication, Anxious, restless, n and the conduction of epidural confused, weak 12 mL / hr nerve impulses, shallow breathing, epidural presumably by metallic taste, slow Name: Section__________ increasing the heart rate with weak threshold for electrical pulse, fever excitation in the nerve, by slowing the propagation of the nerve impulse, and by reducing the rate of rise of the action potential. Epinephrine Broncodilation. Severe hypotension 10 mg q 5 min IV maintenance of heart tremor, angina, rate and BP. Affects tachycardia, beta1/beta2 receptors. hypertension Lactated Ringers Source of electrolytes, 125 mL / hr IV calories and water for thrombosis, hydration. phlebitis , Hypotension Nervousness, Fever, venous Name: Section__________ Labor Assessments Document assessments at least every hour. Add pages as needed. Hourly Assessment—include q15 min data if pt is receiving Oxytocin or Epidural Time 0710 Stage of Labor first Phase__active___ Dilatation_not available_ Effacement___not available__ Station__around +3 - +5___ How is client coping w/ labor not in pain, showing some slight discomfort due to numb legs Nursing Interventions—document what you or the nurse are doing in the following areas: Supportive (e.g. teaching, back rub, relaxation, position change, etc) position change when changing the pad ______________________________________________________________________ Nutrition/ IV (fluids, rate, site & assessment) Elimination catheter placed 09/04 c 0350 _______________________ Medications (drug, dose, route, time) & Client response IV fluids in left metacarpal . 18 gauge, no redness or swelling Other: Include any pertinent medical interventions that might have taken place in the last hour as well. category 2, fetal heartrate absent. HR accelerations > 15 __________________________________________________ _____________________________________________________________________ Hourly Assessment—include q15 minute assessment if pt is receiving Oxytocin or Epidural Time 0730 Stage of Labor first Phase_transition__ Dilatation__not available___ Effacement__not available___ Station___around +3-+5__ How is client coping w/ labor legs not in pain, showing some slight discomfort due to numb Nursing Interventions—document what you or the nurse are doing in the following areas: Supportive (e.g. teaching, back rub, relaxation, position change, etc) position change, and use of peanut ball on left side. Nutrition/ IV (fluids, rate, site & assessment) redness or swelling Elimination catheter IV fluids in left metacarpal. 18 gauge, no _________________________ Name: Section__________ Medications (drug, dose, route, time) & Client response Other: Include any pertinent medical interventions that might have taken place in the last hour as well. ___________________________________________________________________________ _______ ___________________________________________________________________________ _______ Hourly Assessment—include q15 min data if pt is receiving Oxytocin or Epidural Time 0830 Stage of Labor Phase_transition_ Dilatation_7.5__ Effacement_100%__ Station__+5___ How is client coping w/ labor Emergent c-section due to category 3 strip Nursing Interventions—document what you or the nurse are doing in the following areas: Supportive (e.g. teaching, back rub, relaxation, position change, etc) position change Nutrition/ IV (fluids, rate, site & assessment) redness or swelling Elimination catheter IV fluids in left metacarpal, 18 gauge, no __________________ Medications (drug, dose, route, time) & Client response Other: Include any pertinent medical interventions that might have taken place in the last hour as well. ___________________________________________________________________________ _______ ___________________________________________________________________________ _______ Hourly Assessment—include q15 min data if pt is receiving Oxytocin or Epidural Time 1100 Stage completed Phase_complete__ Dilatation_complete_ Effacement_complete_ How is client coping w/ labor completed Nursing Interventions—document what you or the nurse are doing in the following Name: Section__________ areas: Supportive (e.g. teaching, back rub, relaxation, position change, etc) ___________________________________________________________ Nutrition/ IV (fluids, rate, site & assessment) Elimination _________________________________________________ Medications (drug, dose, route, time) & Client response cefazolin 2g/20mL IV syringe at 1030, lactated ringers IV infusion 125mL/hr new bag at 1017 Docusate sodium capsule 100 mg oral at 1030 Other: Include any pertinent medical interventions that might have taken place in the last hour as well. ___________________________________________________________________________ _______ Birth If Client delivers, provide the following information: Time 0907 Type c-section Sex of Infant girl Wt 7lbs 4oz Length 20in Position__op__ Apgar Scores 1 min 8 5min 8 If you know what were points taken off for Complications category 3 strip heart tones Describe bonding/breastfeeding following the birth after skin on skin contact immediately after birth, sweet talking, successful nursing with strong attachment LIST & PRIORITIZE NURSING DIAGNOSES with etiology (RT) and SYMPTOMS (AEB) that occurred during labor (remember to include the fetus) 1. Risk for infection related to invasive procedure and rupture of amniotic membranes. 2. Risk for allergic reaction related to allergy to common medications: codeine and penicillin. Name: Section__________ 3. Risk for acute pain during c-section related to psychological reactions of unnatural feelings of applied pressure. LABOR FLOWSHEET *use the key on the next page to fill in the blanks Data/time 09/04/2019 Vital Signs Temp C Pulse Respirations Blood Pressure Uterine Activity Monitor Mode—TOCO or IUPC Contraction Frequency Contraction Duration Contraction Quality Irritability 0645 98.3 104 16 104/51 TOCO 4-8 mins 30-45 secs Moderate by 0845 1000 1100 1226 88 84 16 108/52 81 16 103/63 36.7 81 16 105/66 103/54 IUPC 2-5 mins 45-60 secs palpation Soft by palpation Resting Tone IUP IUPC Intensity IUPC IUPC Placement Fetal Assessment FHR Baseline Rate Variability Accelerations Decelerations (Early, Late, Variable) FM Interventions Internal Scalp Electrode Pain Pain Rating 10 65 Normal - 130 Absent/undetec Variable/reoccu 4 Name: Section__________ Pain Presence Complains of pain/discomfor tshows nonverbal indications sharp Left; incisional Pain Type Pain Location Labor Coping Assessment Pain Relief Measures Medication timing Vaginal Exam Dilation Effacement Station Membrane Status Membranes Ruptured Data/Time Membranes Rupture Method Amniotic Fluid Color Amniotic Fluid Amount Amniotic Fluid Odor Maternal Assessment Vaginal Bleeding Bleeding Amount Deep Tendon Reflex Clonus Education L&D Teaching/Delivery Irritability None Occasional irritability Irritability with contractions Irregular irritability Denies feeling contraction Coupling contractions Monitor Mode E-External I- Internal 6 100 -1 Ruptured 9/04/19 at 0645 AROM clear moderate Not present 7.5 100 -1 Not present Baseline Changes No Change Bradycardia Tachycardia Sinusoidal Variability Absent <3bpm Moderate variability 6-25 bpm Marked variability >25 bpm Accelerations 15x15 10x10 prolonged Decelerations None Late Variable Prolonged Membranes Intact Bulging Ruptured ROM Method Spontaneous Artificial FM Interventions Position change Oxygen applied Vaginal Exam Blood pressure Provider notified Fetal scalp stimulation Pitocin dc’d FM Procedures Toco adjusted Ultrasound adjusted Fetal monitor applied Fetal monitor reapplied Pushing FHR not tracing Name: Section__________ LABOR FLOWSHEET page 2 Data/time 09/04/2019 Medications Pitocin Pitocin rate Magnesium Magnesium Sulfate rate Medications Administered PRN Medication Response Interventions Oxygen Amount Oxygen Device Patient Position Patient Activity Comfort Measures Hygiene Communication Provider Notification Report to Information reported Orders received Decision for C/S Delivery Universal Protocol Procedures Decision for C/S Delivery Hygiene—Abdominal Prep IV 0645 81/min nonrebreather Trendelenburg Left IV location IV Angio size IV Attempts IV Site Status C/S Prep Nitrazine (pos/neg) Bedside Glucose NST Results Anesthesia Epidural preparation Time Out Performed at: Epidural Procedure Annotation Comment . metacarpal 18 gauge 0845 81/min nonrebreather Trendelenburg Left metacarpal 18 gauge 0901 1000 81/min nonrebreather Left metacarpal 18 gauge 1100 81/min nonrebreather Left metacarpal 18 gauge 1226 81/min nonrebreather Left metacarpal 18 gauge