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Discussion

Care plan discussion - first OB care plan

This is my first care plan in my OB rotation.

The patient is post-partum. G2P2. Cesarean. The bladder sustained an injury and was nicked by a surgical retractor. Patient had a small bladder repair and would require a Foley to go home until the bladder healed. Patient had post c-section pain as well as belly pain from bloating and gas. Urine was bloody and with clots. She still had the epidural and could not use her legs to get up an about. She was bowel incontinent w/diarrhea d/t her epidural when we assumed her care at beginning of shift.

We must have the top three (3) priority goals. My goals are currently ordered based on the prioritization of human needs they give us for the program. I could see taking # 1 and making it # 3 because her pain and clogged Foley seemed to be the more "acute" problems of our day. The self-care deficit was an issue, but it was never an urgent thing. I would appreciate feedback on my thought process so I make sure I'm following the proper thought pathways.

1) Self-care deficit d/t epidural catheter and inability to sense bowel movements or to ambulate. Patient has expressed a desire to discharge epidural catheter POD 1. Goal: Patient will regain functional continence and ambulation by end of shift.

2) Acute pain relating to Low Transverse Caesarean Section, intermittently clogged Foley and gas pains. Goal: Pain will be 3 or less on 1-10 scale by end of shift.

3) Impaired urinary elimination d/t Foley catheter and blood and clots in urine. Goal: Patient catheter will remain patent and draining throughout shift.

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    This is what I have gotten as I worked through my paperwork:

    1) Impaired urinary elimination r/t recent bladder injury and repair. Goal: Foley catheter will remain patent and draining throughout shift.

    2) Acute pain r/t LTCS, intermittently clogged Foley and gas pains. Goal: Pain will be 3 or less on 1-10 scale by end of shift.

    3) Self-care deficit r/t bowel incontinence and inability to ambulate due to epidural catheter. Patient desires removal of epidural this day. Goal: Patient will regain functional continence and ambulation by end of shift.

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    Your goal for: Impaired urinary elimination and self care deficit are not measurable goal.

    How do YOU think you can measure the outcome?

    Why is a measurable goal important?

    Draining doesn't cut it. Think about it. It will remain draining? Okay .... little more details please!

    Regain functional continence? Is there a way you can measure functional continence?

    What about ambulate? Patient will ambulate? Give me details? How will they ambulate? Where to? How far?

    Oh and all of your diagnoses need an "as evidenced by". It really is straight forward. Pretend I am the nurse and you tell me they're having trouble voiding ... what typically will the nurse follow that with in report? Is the RN gonna just say "oh pt has had issues voiding... bye" noooo right? She or he will say "they've been having trouble voiding ... yeah she (insert evidence)".

    Make sense?

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    Just off the top of my head I will say remember that urinary elimination can be measured by urinary out put, so what is the normal output that can tell you that she's not having urinary retention?

    Also personally I would be more concerned about infection or dvt than the self care deficit. While it is a risk only, it seems to be a high risk as post op, Foley, and incontinent. The fact that she's post partum, immobile and cannot use her legs puts her at risk for clots.

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