OB PIH Careplan

Published Dec 1, 2007

5 Posts

Hi there! I'm new to the forums, so first off hello! Thanks for all the help you guys give everyone. I am a second year nursing student (1 semester to go). I have always done fine with care plans except for OB. This is my last OB L&D rotation and the careplan has to be high risk. There were no high risk patient's so I was given a case study scenario. I would appreciate any help with goals, interventions, etc. The scenario is as follows:

A 15 year old Gravida 1, African American female was admitted to the hospital after her blood pressure at the clinic was found to be 178/120. Urine protein was found to be 3+. She has not had any prenatal care until today. She was determined to be 35 weeks by dates and sonogram. She complained of a headache and her mother insisted that she see the doctor today.

Physician's Orders:

Diagnosis: Severe preeclampsia with HELLP syndrome

Place on continuous fetal monitor.

Seizure precautions

Group B strep protocol. Penicillin G 5 million units now and 2.5 million units q 4 h until delivery.

Bedrest in left lateral position.

Limit visitors to parents and boyfriend only.

IV- Ringers Lactate at 125 cc/hr.

Begin induction of labor with oxytocin according to protocol.

Demerol 50 mg IV prn for pain

Phenergan 25 mg IM prn for nausea

Insert Foley catheter, Intake and output q 1 hour.

Continuous pulse oximetry

Magnesium sulfate IVPB 4 gram loading dose in 100cc of NS over 20 minutes and then 2 grams per hour.

(Total IV fluids not to exceed 150 cc/ hour.)

DTRs and clonus q1h.

VS and LOC Q1h

Lungs sounds Q1h.

Magnesium Sulfate levels q4h.

Urinalysis

CBC with platelets, complete metabolic profile including liver enzymes.

Drug Screen

Hydralazine 10 mg IV push prn SBP>160, DBP>110

Nursing Assessment on Admission:

She denies visual problems and epigastric pain but states her headache is worse (8/10)

She states that she has had an 8 pound weight gain during the last week.

"I am so afraid. It is too early for my baby and my boyfriend is not here. My Mother and Daddy are mad at me because I didn't tell them I was pregnant."

"My hobbies are dancing and watching TV."

Personal Social: Denies use of tobacco, alcohol or drugs.

Lives with both parents and one 7 year old brother.

House with adequate heating and cooling, indoor plumbing and no noted safety hazards.

Sophomore in high school. "I like school, I was hoping to try out for cheerleader next year." Both parents present and seem appropriately concerned about their daughter.

Past Medical History: No illnesses or accidents requiring hospitalization. No current medications. Immunizations up to date.

OB History: Gravida 1. No prenatal care until today.

Height - 5'4"; Weight 145 lbs. " I weighed 110 lbs before I got pregnant."

Admission vital signs are: T-98.6 degrees F, P-82, HR-20, BP-180/116.

Alert and oriented X3.

Some facial edema noted.

2+ edema of hands.

Breath sounds-- Clear vesicular sounds in all lung fields, Pulse oximetry 98% on room air.

Abdomen is soft and nontender with active bowel sounds in all four quadrants.

DTRs 2+ and = bilaterally, negative clonus;

3+ pitting edema of feet and ankles

Dorsalis pedis Posterior tibilalis pulses 2+ and + bilaterally.