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cutieqq88

cutieqq88

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  1. Can someone take a look at my care plan? Thank you so much!!! Assessment: T = 98.5 F Oral O2=97% P=64, reg, +3 R = 18, reg, unlabored bp = 122/86 Pain = 3/10 Objective: Breast - soft, nipples intact and non-tender Uterus: Fundus firm, U2 at midline Perineum - mild edema 1o laceration Bowel: active bowel sound x 4 quadrants Voiding - qs, clear, yellow Lochia - moderate rubra, no clots Extremities: MAE Bilateral pedal non-pitting edema Bilateral upper extremities non-pitting edema Treatment - Ice pack, topical Knee high TEDS RBC: 3.56L HgB: 10.9L Hct: 32.4L WBC: 16.6H Three nursing diagosis (Priortized) 1. Risk for infection r/t mild perineum edema, high WBC post-delivery s/t 1 degree laceration from NSVD 2. Ineffective breastfeding r/t pt unable to latch infant s/t first time mother 3. Acute pain r/t "3" on pain scale of 1 - 10 d/t breastfeeding causd contraction of the uterine. Care Plan for Risk for Infection Long Term Goal: Patient will remain free from symptoms of infection by discharge. Short Term Goal 1: Pt will state 3 symptoms of infection by the end of the shift. Short Term Goal 2: Pt will demonstrate appropriate perineal care by the end of the shift. Nursing Intervention: 1. Nurse will assess perineum for infection every 4 hours 2. Nurse will assess peri pad for amount and color every 4 hours. 3. Nurse will apply epifoam PRN for discomfort 4. Nurse will teach pt to inspect perineum and explain the signs that may indicates infections at beginning of shift. 5. Nurse will provide pt with ice pack PRN for discomfort ANY COMMENTS???
  2. Can someone take a look at my care plan? Thanks a million!!! Assessment: T = 98.4 F Axillary HR = 128, murmur R = 24, irregular Pain = 0 / 6 Objective: Birth weight: 8 lb 1oz / 3657.09grms Length 21 inches / 53.34cm AGA Gestational age - 40 weeks Capillary refill Skin - dry, + turgor, pink Activity - MAE Muscle tone - flexion Cry - lusty Suck reflex - fair Fontanelles - soft and flat Respiratory / Cardiovascular - murmur Abdomen - present active Breastfeeding - average 5 minutes Voiding - qs, clear, yellow Stools - qs, transitional, meconium, green Molding Milia Umbilicus - redness, swelling Three nursing diagnosis (prioritized): 1. Risk for aspiration r/t R = 24, burp d/t immaturity of baby's internal organs. 2. Immbalanced nutrition r/t fair performanace of sucking reflex d/t insufficient intake. 3. Risk for infection r/t redness and swelling around umbilicus d/t removal of umbilicus cord. Care Plan on Risk for Aspration: Long Term Goal: Pt will maintain breathing pattern by discharge. Short Term Goal 1: Pt's respiratory rate will remain between 30 to 60 by end of the shift. Short Term Goal 2: Pt's O2 Sat. will remain > 95 by end of shift. Nursing Intervention: 1. Nurse wil assess pt's vital sign every 4 hrs. 2. Nurse will bulb cution secretions as needed all shift. 3. Nurse will assess pt's respiratory system every 4 hrs. 4. Nurse will asses pt. O2 Sat. once every 4 hrs. 5. Nurse will burp baby as needed all shift. ANY COMMENTS??? :)
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