LABOR AND DELIVERY

CASE STUDY
Kelsi Noeth

Demographic Data

Patients Initials: A.S.

29 y/o Caucasian female
Why in the hospital? C-section at 37
weeks, 5 days.
In the labor and delivery unit
Breastfeeding or formula? Breastfeeding
G1P1
First child

Past Medical History

Blood type: O negative

Negative for HIV, strep, hepatitis
NKDA
History: Pleurisy, Irritable bowel
syndrome
Past Surgeries: Coronary endarterectomy
c/o constipation

Family Medical History

Mother: Type 2 Diabetes

Father: myocardial infarction

Both parents have hypertension .

Psychosocial

Esthetician, but currently unemployed

Insurance: Medicaid
Education: HS diploma and cosmetology
school
Negative for tobacco, drug, or alcohol use
Married to father

Nursing Theory

Virginia Hendersons Nursing Need

Theory

Three assumptions identified

Four major concepts

Fourteen components

Developmental Theory

Imogene Kings Goal Attainment Theory

Roles, stress, space, time
Three interacting systems

Growth and Nutritional Status

Height: 57
Weight: 191 pounds
BMI: 29.9
Appearance: Considered overweight
Nutrition: Adequate nutrients
G1 P1
Baby
50% percentile
Slightly pre-term so needed blood sugars

Focused Physical
Assessment

Vital Signs
T: 97.6 F
P: 82
RR: 16
BP: 140/82
O2: 98% on room air

General Appearance
A&OX4
Well-groomed
Speech clear, no slurring

Focused Assessment
Continued

Lymph Nodes:

Non-tender and non-palpable.

HEENT
Facial features symmetrical
Denies sinus pain
PERRLA

Heart

Regular rate and rhythm. No murmurs noted.

Chest/Lungs

Clear upon auscultation posterior and anterior.

Focused Assessment
Continued

Extremities:
Cap refill <3 seconds
No signs of edema
Posterior tibialis and dorsalis pedis pulses 2+
and regular
Radial pulses 2+ and regular
No signs of cyanosis of extremities
ROM WNL

Neuro:

Grips equal bilaterally

Labs

Platelets: 350,000 mcL

Hemoglobin: 12.9
Hematocrit: 37.8%
WBC: 9.5 K/UL
Rubella: immune
RBC: 4.83 m/UL

Medications

Bicitra
Treats metabolic acidosis and certain kidney problems
(kidney stones). Neutralizes acid in the blood and urine.
Reduces acidity of mothers stomach contents.
SE: diarrhea, loose stools, nausea, upset stomach, vomiting
Breastfeeding: discuss risks with doctor, unknown if it is
excreted in breast milk.

Tordol
NSAID; works by reducing inflammation and pain in the
body; short term (5 days or less)
SE: upset stomach, N&V, diarrhea, constipation, mild
heartburn, stomach pain, bloating, headache, sweating
Breastfeeding: not recommended

Demerol
Used for pain control
SE: shallow breathing, drowsiness, confusion, agitation,
tremors, dizziness, N&V, sweating
Breastfeeding: use with caution

More Medications

Phenergan
Antihistamine; helps with itching, runny hose, sneezing,
watery eyes, hives, skin rashes
Also treats N&V after surgery
SE: drowsiness, dizziness, ringing in ears, double
vision, nervousness, dry mouth, fatigued
Breastfeeding: use with caution

Ondansetron
Used for treatment of nausea and vomiting
SE: headache, dizziness, drowsiness, fatigue,
weakness, constipation, diarrhea, dry mouth and
extrapyramidal reactions.
Breastfeeding affect: not recommended

Implications

A.S. needs to be educated, most importantly, on

nutrition and any signs and symptoms of an
infection occurring at her incision site.
It is important that she has the knowledge to understand
her risk of type 2 diabetes and hypertension. Diet
changes should be made, and a sufficient amount of
fluid should be ingested. There needs to be a regular
exercise routine, as well.
She should be made aware of signs and symptoms of an
infection occurring at the incision site from the c-section.
If redness, tenderness, fever, and drainage starts to
appear, the physician needs to be notified. She needs to
monitor her temperature to ensure a fever is not
developing.

Nursing Diagnoses

1) Acute pain r/t cesarean delivery as e/b patient

complaints of pain.

Outcome:
The patient will report a numeric pain of less than 2 on a 0-10

pain scale by the end of the shift.

Interventions:
The nurse will assess the patients pain level before and after

the administration of medication.

The nurse will administer pain medication to the client as
needed.
The nurse will explain to the patient to inform the nurse when
the pain begins to worsen.
The nurse will educate the patient about possible side effects
and to inform the physician of any adverse reactions.

Evaluation:
Goal met. The patient had a pain of 2 on a 0-10 scale by the

time she went to postpartum. Continue goal.

Nursing Diagnoses

2) Knowledge deficit r/t self-care and breast feeding as

e/b the mother having her very first child and asking a
lot of questions about what to expect.

Outcome:
The patient will be confident in her knowledge and have all of her

questions for us answered by the end of the shift.

Interventions:
The nurse will assess the patients current knowledge about self-

care and breastfeeding to determine education needed.

The nurse will discuss the psychological and physiologic changes
that many expect after childbearing.
The nurse will educate the patient about breastfeeding tips and
how to determine if the newborn is hungry.
The nurse will educate the patient about how to perform perineal
care.

Evaluation:
Goal met. The patient felt more knowledgeable and confident

about her self-care techniques and breastfeeding. Continue goal.

Nursing Diagnoses

3) Risk for infection r/t cesarean birth and having a Foley

e/b having an abdominal surgical incision and needing
thorough catheter care.

Outcome:
The patient will remain free of infection by the end of the time spent in

labor and delivery.

Interventions:
The nurse will assess the C-section incision sight on a regular basis,

paying special attention to redness, fever, discharge, and tenderness.

The nurse will take the patients vital signs frequently to assess for an
increase in temperature and pulse, which are signs of infection.
The nurse will monitor the patients WBC counts regularly.
The nurse will provide catheter care twice a day to ensure its
cleanliness and prevent UTI.
The nurse will educate the patient on the signs and symptoms of an
infection in the incision, including redness, drainage, and fever. For UTI,
the patient will experience irritation and urinary retention and stinging
upon urination.

Evaluation:
Goal met. The patient did not have any signs of infection while on labor

and delivery. Continue goal for rest of hospital stay.

References
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