Labor Assessment

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ASSESSMENT /N URSING CARE P LAN R UBRIC

StudentName: Shalama Day

Date: 3/21/2012

Each item listed below is worth 1 point (10 possible points) (< 8 points resubmit)

Other Documentation Self-Evaluation Instructor EvaluationRubric Included 1

Shift Report Completed 1

AssessmentComplete Patient Data 1

Complete Labs 0.5

Complete Medication Information 1

Problems Highlighted 1

Appropriate Medical Terminology 1

Nursing Care PlanAppropriate NANDA 1

Evidence Based 1

Quality of Work, Spelling,Grammar

0.5, always been weakwith spelling. Spell checkdoes not recognize all of the medical terms

Total: 9

1 | P a g e


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LABOR & B IRTH /N URSING CARE P LAN

Fill out completely. As you fill in the document the table cell will wrap the text that youenter and the table will expand to contain your complete answer. Highlight with yellow any

problems or needs.Student Name: Shalama Day PTs Initials: MGDate of Assessment:

3/21/2012 Co RNsInitials:

DL

Pregnancy Information:Age 25 EDC

3/26/2012Wks.gest.39/2

G 1 P 0

G 1 T 0 P 0 A 0 L 0PRE pregnancy General Health (include gynecological history and past medical and surgicalhistory): History of migraines, asthma, and no past surgical history.

Past Pregnancies (weight gain, complications, newborn wt., etc.): N/A

Psychosocial History (family composition, financial status, employment, cultural issues, etc.):Married for 3 years to husband Mark. Worked as nanny fro the past year. Attends church andhas close ties to friends in the church. Mother deceased, father and siblings all live out of state.

THIS Pregnancy: Type of Prenatal Care: Care of MD in local office in the town of Clinton, MI. Was admittedinto St. Joes for migraines in January 2012.

Prenatal Education: Did not take any prenatal classes. Books and Nanning where her

source of education.Nutrition And Weight Gain: Pt. states that her diet was good through out the pregnancy.Weight gain of 35 lbs.

Substance Use (tobacco, alcohol, drugs, etc.): Denies tobacco, alcohol and drugs use.

Medications Taken During Pregnancy: Vicodin, Tylenol 3 for migraines. Prenatal vitamin.

S TAGE O NE LABORCalculate:

Hours:

24 Minutes: 45

(length for your patient) 24 hour and45 minutes

*Define LATENT PHASE : (Include average length of time for a primipara and amultipara.) 0-3cm cervical dilation, 0-40% effacement. Nullipara/primipara may last upto 9 hours, multipara, last up to 5-6 hours. Contractions last 30-45 seconds and areevery 5-10 minutes, intensity mild to palpation.

Describe your patients latent phase. The records indicate that the patient spent thisphase trying to control the pain and stay comfortable. Nursing notes indicate that shewas anxious and concerned about the discomfort of the birthing process.

Your Patients Status on Admit: Admitted to L/D on 3/19/2012 for induction


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due to IUGR.Onset of labor:Induction

AM/PM induction at 1930on 3/19/2012

Dilation: Cervadil given at 21:15 on 3/19.No progression started Pitocin at 09:15 on3/20. 1-2 dilation

Station: -2 Effacement: 70%

*Define ACTIVE PHASE: (Include average length of time for a primipara and amultipara.) 4-7cm cervical dilation, effacement 40-80%. Primipara, lasts up to 6 hours,mulitpara, last up to 4 hours. Contractions last 45-50 seconds and are every 2-5minutes, intensity moderate to palpation.Describe your laboring woman. What coping skills was she using? Not observed

What was your, the nurses, and physicians assessment of your client? Not observed,records of nursing notes stated that labor was lagging

Amniotic Fluid: lightmeconium

T: time of rupture:20:10

A: amount notobserved

C: colorlightmeconium

O: odornotobserved

Antibiotic used for B strep ortemp:

Yes No Significance: Use of antibiotics for a motherthat tested positive for GBS are to protectthe newborn against colonization of GBSbacterium, which would causeoverwhelming neonatal sepsis. For anincreased temperature may be a side effectof chorioamnionitis. Antibiotics are given todecrease the rick of infection.

FHT ranges? 123-190 Maternal vital sign ranges? T: 98.8-101.3

HR: 93-129, RR 16-18, B/P 91/54-129/74Duration, interval, and strength of contractions? Not observed for active phasePain control: YES IVP: Morphine 5 mg

at 05:30 on 3/20Epidural: yes,Fentenal Citratewith Bupivcanisstarted at 12:50 on3/20

10ml/hour in 250ml

None: N/A

*Define TRANSITION: (Include average length of time for a primipara and a

multipara.) 8-10cm cervical dilation, 80-100% effacement. Primipara, last up to 1 hour,multipara, last up to 30 minutes. Contractions last 60-90 seconds and are every 1-2minutes, intensity is strong by palpationWhat symptoms and behaviors did you observe? Not observedHow was your patient assisted through this phase of labor? Pt. was assisted by midnightnurse and husband

*What interventions were done during Stage One of Labor for comfort, safety, nursingcare, and to enhance her labor progress? Include medical and nursing procedures

(AROM, EFM, IV, etc.) carried out and RATIONALE for each.


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Nursing and Medical Procedures RationaleCervidil Induction/cervical ripeningIV- Lactated ringer Fluid and Electrolyte

replacementAROM/AmniotomyOxytocin/Pitocin Drip

Induction/Accelerate labor

Who or what interfered with your laboring womans comfort or confidence? Was any of this avoidable? What else could have been done or said to support her? This first timemother did not have much support, other than her husband. She was diagnosed withIUGR, which lead her to be induced. The induction lead to one intervention and then toanother. Stage 1 of labor was such a long process for her that she could not take thepain, which lead to more interventions of pain management. This all may have beenavoided if there was another ultrasound done to rule out IUGR. The mother and fathercould have had someone else there for support, laboring is an exhaustive process and itmay have been helpful to have someone like a doula to help the family through it.What information or support was provided for her labor partner? Not much, by the timemy nurse and I came into the room the husband was exhausted. We where able to givehim a break to eat, but that left the mother alone and she was not the happiest aboutthat.

S ECOND S TAGE LABOR*Define SECOND STAGE: (Include average length of time for a primipara and amultipara.) From complete dilation to birth of the newborn; lasts up to an hour forprimipara and 30 minutes for multipara. Pelvic phase is the period of fetal descent andPerineal phase is the period of active labor. Strong urge to push during the later perinealphase.Completelydilated at:

06:25

Calculate: Hours:

2hours

Minutes:

16 min.

(length for your patient)

How did your patient move the fetus through the birth canal? Describe her position,breathing, etc.

The pt. was in a semi-fowlers position, with her legs bent, and held by her and husband.

What assistive interventions were carried out by her labor partner, nurse, nursingstudent, and doctor or midwife? A trochanter roll was placed under her pelvis, and atowel bar was placed over the bed with a towel pull. Legs where extended between

contractionsDelivery time of newborn:

09:09

Describe her and her familys reaction at the time of birth.

Husband stayed with the mother and mother was very tired.Once the baby cleaned up and ready to go to the NICU, theywhere able to see her before she went down. Both mother andfather kissed the baby, with tears of joy.


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THIRD S TAGE LABOR*Define THIRD STAGE: (Include scheduled or emergent C/S.) Separation and deliveryof the placenta. The placenta will detach and be expelled from the vaginal opening.PlacentaDelivered at:09:12

Calculate Length inhours:

minutes (for yourpatient) 3minutes

EBL(estimated blood loss) 500mlfor vaginal birth and 1000ml for a c-section400 ml

*Normal number of cordvessels: 3

*Number of cord vesselsobserved:

*Significance of thesefindings: Evidence of onlyone single umbilical arteryis association with renaland gastrointestinalanomalies

Medications utilized and RATIONALE (for C/S also):

Nursing and Medical Procedures RationaleContinued to run Pitocin Help contract the uterus, decreasing the

risk for a hemorrhageMessaged the uterus Contract the uterusMonitor and assist with repair of thelaceration

Must remain with the pt. to providesupport

F OURTH S TAGE LABOR*Define FOURTH STAGE: Beings after the placenta is expelled and lasts up to 4hours after birth, during which time recovery takes place.Include physical conditions, vital signs, and 8 point check:

B: Not able to start breast feeding at this time, baby directly to the NICU U: Checkedevery 15 min., messaged and position assessed. B: Foley straight cath., 350 ml of urine.B: Bowel sound present L: rubra, moderate amount E: stage 3 lacerations, repaired bythe attending resident. Area was bruised. E: Slight edema in legs, feeling returningslowing after the epidural was D/C. E: Mother was exhausted from the long labor. Shewas also upset that the baby had to go to the NICU.Describe ALL nursing interventions done during this stage (be objective). Providedsupport and information about the repair of the laceration. Applied an ice pack to theperineum, to help reduce the swelling and promote comfort. Monitored vital signs andfundal and lochia status every 15 min., documented. Offered warm blankets. Providedurine relief with a foley catheter. Educated the mother about uterine firmness and howto promote the return of the uterine to pregnancy shape.What was done to enhance the attachment process? Baby was brought back to thefamily after two hours in the NICU, promoted holding and bonding with her.Present OBJECTIVE evidence that the mother and father were (or were not) attaching totheir newborn.

Cesarean Birth Questions (use ONLY for cesarean births)What was the reason for the cesarean birth?What was done to prepare this mother for her surgery?How did the mother and her support person(s) cope with the decision to have a surgical


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birth?What anesthetic was used?Describe the operation:Start OR Time End OR Time

Time of Birth Time of Placenta

BABY Apgars: 1

9 5

9 10

Not obtained

What did the nurse do for the neonate right after birth? Neonate was taken care of bythe NICU team

What normal neonatal characteristics did you observe with the physical assessment?Were there any obvious defects?

She was normal at time of birth, there where no obvious defects.

Instructions: Referring to the highlightedproblems/needs, list NANDAS related to labor and birth.

NANDAS (List 5)Health Seeking Behaviors: Labor R/T desire for a safe labor and vaginal birth of ahealthy newborn.Anxiety r/t infectionRisk for Injury: Maternal and Fetal R/TInfection: Maternal/Fetal r/t invasive proceduresRisk for Deficient Fluid Volume r/t decrease intake and increased losses

Choose one NANDA and create one nursing care plan.


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LABSPrenatalResults

AdmissionResults

NormalFinding

s

Explanation(from text)

Hemoglobin L 9.8 gm/dl10-14g/dl

To determine if the pt. isanemic

Hemalocrit L 29.9 %32-42%

To determine if the pt. isanemic

RBC L 3.54 To determine if the pt. isanemic

WBC9.1thou/mcl

5000-15000 /mm3

To determine if there is aninfection present. Willincrease due to immunestress response

Platelets232thou/mcl necessary for coagulation

Blood Typing O+

Rh- mother, birthing a Rh+baby could lead to problemswith future pregnancies

COOMBS Neg.

Antibody screen to determinewhether the mother hasdeveloped isoimmunity to theRh antigen. This test detectsunexpected antibodies in awomans serum that could beharmful to the fetus.

Rubella Titer ImmuneDetermine if you areprotected from Rubella.

Hep B Neg.

Checks for infection with theHepatitis B virus, which canbe passed to an unborn child.

HIV Testing Neg. Neg.

If positive the mother can begiven zidovudine to reduceperinatal transmission.

STI Screening (RPR) Neg.

Pregnant women with STIscan transmit the infection totheir children, resulting insignificant morbidity andmortality

Cervical Smears (PAP)

Not

obtained

checks for abnormal cervical

cellsGroup Beta Strep (GBS) Neg.

GBS may cause anoverwhelming neonatal sepsis

Other15-18 weeks Quad Screen Not

obtained This test measures the levelsof AFP, HCG, estriol, andinhibin A in your blood. Theselevels are then used tocalculate the risk of


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chromosomal or neural tubeabnormalities in your baby.

13-20 weeks AFPNotobtained

Check the fetus of a pregnantwoman for brain or spinalproblems and for Downsyndrome.

28 weeks 1 hr glucose Tolerance Test

Notobtained

This test measures bloodsugar levels to check for risksfor gestational diabetes.

Ultra Sound: Diagnosedwith IGUR,sex of thebaby is agirl

Assess the baby's well-beingand position, diagnosemultiple gestations (twins,triplets, etc.) and estimate adelivery date

Amniocentesis: Genetic screening, recommended for high risk patients.

N/A

Non-Stress Test: a screening test used in pregnancy. A cardiograph is used to monitorthe fetal heart rate.

N/A

* Explain why test was ordered. Correlate abnormal findings to clients condition.

List all other applicable labs drawn on pt during this admission.

Current Medications

Drug Action/Indication Nsg ImplicationsCervidil Directly softens and dilates

the cervix/ cervical ripeningand inducing labor

Provide emotional support

Administer pain medication asneeded

Frequently assess degree of effacement and dilation

Monitor uterine contractions forfrequency, duration, and strengthAssess maternal vital signs and

FHR pattern frequentlyMonitor for adverse effects such as

N/V, headaches and diarrheaOxytocin/pitocin Acts on uterine myofibrils to

contract/augmentation of labor and artificial induction

Administer as an IV infusion viapump, increasing dose based on

protocol until adequate laborprogress is achieved

Assess baseline vitalsMonitor uterine contractions for

frequency, duration, and strengthMaintain careful I & O, be alert for

water intoxicationKeep pt. informed of labor


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progressMonitor for possible adverse side

effects such as hyperstimulation of the uterus.

Epidural, FentanylCitrate andBupivcanin 2mcg/ml

Local anesthetic with opioid/loss of sensation and pain

Monitor fetus for distress

Monitor for hypotension, fever,pruritus and respiratory distress

Assess fetus for respiratorydistress secondary to maternalhypotension

Tylenol 250mg/tabx 2 tabs

Nonnarcotic analgesic, torelieve mild to moderatepain

N/V

Anemia

Zofran 4mg Antiemetic/ to preventnausea and vomiting

May cause flushing of the skin,constipation, and CNS adversereactions such as anxiety,headaches, hypotension andagitation.

Ampillen 2 gm Antibiotic/treat bacterialinfections

Monitor for chills, fatigue,headache

Assess for urine retention

Gentamicin100mg/50ml

Antibiotic/to treat bacterialinfections

Monitor vitals

Assess for confusion, headache,and neurotoxicity

Monitor for respiratory depression

Motrin 500mg/tab Analgesic, anti-inflammatory/relieve mild to moderatepain

Monitor I&O

Assess for GI upset

Assess skin for sigh of a rash

Take with food

Morphine 5mg/IVP Analgesic/provide pain relief for moderate to severe pain

Monitor respiratory status

Monitor vitals

Have pt. change positions slowly tominimize the effects of orthostatic


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hypotension

Monitor pt. for excessive orpersistent sedation

Have oxygen on hand if needed

N URSING 132 C ARE P LAN EXPLANATION

AssessedData

NursingDiagnosis

ExpectedOutcome

NursingInterventionsDx Tx Ed

RationaleScientificResource

Evaluation/SOAPDate TimeSignature


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S: Pt. Statesthat she isvery warmand wouldlike a coolwash clothon herface.

O: Pt. vitalsrange from

Temp. 98.8-101.3

HR: 93-129

RR: 16-18

B/P: 91/54-129/74

Skin warm andflush.

Fetus andmotherbothtachycardic

FHR range123-190

Given AmpillenandGentamicinduringlabor

Lactated ringerrunning125ml/hr

Epidural-Fentanyl/bu

pivcanin

Hyperthermia

R/TPhysiologicresponse to

infectiousprocess.

AEB

Increasedtemp.Suspected

chorioamnionitis

GOAL

Marystemperaturewill be


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contact with peoplewith infection

mia

Pregnantwomenhave aincreasedneed forfluids

Protects thept. fromthe spreadof infection

P: Continue properhand washingtechnique, monitormother for 24 hourafter birth. Provideeducation about S/S

of infection went athome.

SHIFT REPORT/Highlight risks/needs in yellowRoom: L/D 6

TodaysDate: March 21, 2012

SupportNurse: Donna L. Tasks : 700Mothers NameInitials: MGGravi 1 Par 0 Baby: Boy Girl x


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da a800

G 1 T 0 P 0 A 0 L0 Date of Birth: March 21, 2012Allergies/Sensitivities: NKADueDate: 3/26/2012

GestationalAge: 39-2

Time of Birth: 09:09 900

Vaginal Vacuum Forceps APGARScore: 9/9

EBL: 400 ml 1000C-Section:

Breast x Bottle x

Reason: Time of LastFeeding:

Given a bottle in theNICU 1100

Blood Type: O+ Bathed: No

1200RhogramCandidate: Neg.

Hepatitis BVaccine:

GBS: PositiveNegativ

e x Circed: 1300

Hepatitis B: PositiveNegativ

e xNewbornScreen:

1400

Rubella: Immune xNot

ImmuneHearingScreen:

Referral

s:Lactation Birth Weight: 6lbs 14oz, or 3118 gm 1500

PresentWeight:Weight Loss:% WeightLoss: 1600

Void Stool1700

Medications:

Cervadil, Morphine, Zafran, Tylenol,Fentanyl/Bupivcanin epidural

Medications:

Ampillen and Gentomicen for chorioamnionitis Vit. K

Lactated Ringer Eythromycin Ophthalmic Ointmemt 1800Pitocin Ampillen and GentomicinMotrin

1900

Risks/Needs/NANDA:

Risks/Needs/NANDA:

Hyperthermia r/t physiologic response to infection At risk for infection 2000Anxiety r/t the effects of prenatal infection on fetus

2100


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2200

2300

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