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OB Concept Map 2 Olivia Jones

Peds and OB
Course

Parent Child Health (PCH 101)

9 Documents
Students shared 9 documents in this course
Academic year: 2021/2022
Uploaded by:
Anonymous Student
This document has been uploaded by a student, just like you, who decided to remain anonymous.
Holy Name Medical Center Sister Claire Tynan School of Nursing

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OBENur402Maternal Newborn

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S&S:

Hypertension- Nausea - Pain; headache and epigastric - Visual changes - Facial Edema - Pitting dependent edema- Diaphoresis MEDS: LR 1000mL at 125mL/Hr Magnesium sulfate 6g in 1000mL at 200mL/hr LABS & TEST: Platelets 98 RBC 5 MCH 28 MCHC 12 Creatinine 2 BUN 32 ALT 40 AST 42 LDH 220 Triglycerides 180 Creatinine clearance 154

NURSING DX 1: Fluid volume deficit - Related to: preeclampsia - Evidence by: sudden weight gain, increased BP and edema

NURSING DX 2: At risk for maternal injury - Related to: seizures - Evidence: hypertension and proteinuria

NURSING DX 3: Acute pain - Related to: headache - Evidence by: Patient rates the pain level as 5 out of 10

GOALS:

- Short Term: Patient is normovolemic as **evidenced by urine output, edema and BP

  • Long Term: Patient verbalizes understanding of** the causing factors essential to correct fluid deficit.

GOALS:

**- Short Term: Patient will remain calm

  • Long Term: Client is safe and injury free in the** event that she does experience a seizure

GOALS:

- Short Term: The patient demonstrates the use of appropriate diversional techniques and **relaxation skills.

  • Long Term: Patients well-being will improve** and pain level will decrease upon re- evaluation.

INTERVENTIONS:

  1. Insert and IV catheter to have IV access. R: The patient has been prescribed lactated ringers to correct the fluid volume deficit therefore we will administer to the patient. This parenteral fluid replacement is indicated to prevent or treat hypovolemic complications. (Phillips, L, Ralph S. & Taylor, CM) 2 intake and output will be strictly monitored. R:Monitoring of fluid intake will ensure that the patient has proper intake of fluid and other nutrients. Monitoring of output helps determine whether there is adequate output of urine as well as normal defecation. (Phillips, L, Ralph S. & Taylor, CM)
  2. If the patient can tolerate oral fluids, give what drink she prefers. Ensure there is easy access to this beverage near the client's bed. R: Due to other symptoms the patient may have reduced sense of thirst and may require continuing reminders to drink also instills good habits of having a drink close by to encourage hydration. (Phillips, L, Ralph S. & Taylor, CM)
  3. Educate the patient about possible cause and effect of fluid losses or decreased fluid intake. R: Patient knowledge aids them in being able to actively take part in her plan of care. (Phillips, L, Ralph S. & Taylor, CM)

INTERVENTIONS:

  1. Enforce seizure protocols: use and pad side rails with the bed in lowest position and clear the bed of any objects R: Prevents or minimizes injury when seizures occur while the patient is in bed. (Carpentino-Moyet, L.)
  2. Administer magnesium sulfate to patient R: Magnesium sulfate should be used for the prevention and treatment of seizures in women with severe preeclampsia or eclampsia. Caring for the pre-eclamptic woman needing magnesium therapy to prevent seizures. (Carpentino-Moyet, L.)
  3. Position pt on side, administer O2 if seizure occurs R: Helps maintain airway patency and reduces the risk of oral trauma but should not be “forced” or inserted when teeth are clenched because dental and soft-tissue damage may result. (Phillips, L, Ralph S. & Taylor, CM)

INTERVENTIONS:

1 factors that alleviate pain such as dimming the lights/ reducing stimuli. R:The patient does not want medicine for the pain, so we must inquire about providing other alternatives to manage the pain to provide comfort to her. (Phillips, L, Ralph S. & Taylor, CM) 2. Acknowledge and accept the client’s pain. R: We ask our patients about their pain and believe their reports of pain. Challenging or undermining their pain reports results in an unhealthy therapeutic relationship that may hinder pain management and deteriorate rapport.(Phillips, L, Ralph S. & Taylor, CM) 3. Educate the patient about the pain management approach that has been ordered and the risks and side effects associated. R: One of the most important steps toward improved control of pain is a better patient understanding of the nature of pain, its treatment, and the role the patient needs to play in pain control. (Carpentino-Moyet, L.)

Evaluation: Will continue to monitor patient for signs that fluid volume deficit is improving.

Evaluation: The patient is safe and is educated on the environmental modifications to protect themselves.

Evaluation: Will continue to reevaluate patients pain level and provide comfort measures to her.

References:

Carpentino-Moyet, L. (2006) Handbook of Nursing Diagnosis. Lippincott Williams & Wilkins.

Jones & Bartlett Learning (2020) 2020 Nurse’s Drug Handbook (Nineteenth Edition) Burlington MA.

Phillips, L, Ralph S. & Taylor, CM. (n.) Nursing Diagnosis Reference Manual (Tenth Edition) Wolters Kluwer

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OB Concept Map 2 Olivia Jones

Course: Parent Child Health (PCH 101)

9 Documents
Students shared 9 documents in this course

University: Holy Name Medical Center Sister Claire Tynan School of Nursing

Was this document helpful?
S&S:
Hypertension- Nausea - Pain; headache and epigastric -
Visual changes - Facial Edema - Pitting dependent edema-
Diaphoresis
MEDS:
LR 1000mL at 125mL/Hr
Magnesium sulfate 6g in 1000mL at 200mL/hr
LABS & TEST:
Platelets 98 RBC 5 MCH 28 MCHC 12 Creatinine 2.6 BUN
32 ALT 40 AST 42 LDH 220 Triglycerides 180 Creatinine
clearance 154
NURSING DX 1: Fluid volume deficit
- Related to: preeclampsia
- Evidence by: sudden weight gain, increased
BP and edema
NURSING DX 2: At risk for maternal injury
- Related to: seizures
- Evidence: hypertension and proteinuria
NURSING DX 3: Acute pain
- Related to: headache
- Evidence by: Patient rates the pain level as 5
out of 10
GOALS:
- Short Term: Patient is normovolemic as
evidenced by urine output, edema and BP
- Long Term: Patient verbalizes understanding of
the causing factors essential to correct fluid
deficit.
GOALS:
- Short Term: Patient will remain calm
- Long Term: Client is safe and injury free in the
event that she does experience a seizure
GOALS:
- Short Term: The patient demonstrates the use
of appropriate diversional techniques and
relaxation skills.
- Long Term: Patients well-being will improve
and pain level will decrease upon re-
evaluation.

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