Plan of care. A pregnant mother of 20 years, gestational
Plan of care.
A pregnant mother of 20 years, gestational diabetic, with 38 weeks of gestation is
admitted for cesarean section, due to a previous cesarean section by CPD. She practices the
C-section 16 hours ago. She taxes 2, For 2, abortions 0. She is married. Height 5′ weight 120lbs,
American nationality.
Dear: the following findings are found:
Temperature 37.5 centigrade, pulse 85, blood pressure 110/70. vaginal bleeding
moderate with clots, uterine involution (uterus at the level of the navel), soft breasts,
has foley catheter drained, amber yellow urine, NPO, IV fluids coming down
the vein, right peripheral, the area appears clean and dry.
Abdomen sensitive to touch, vertical suprapubic incision, clean and dry. She has peristalsis,
she looks tearful with a lot of pain (scale of 9), and she is afraid that her wound will not heal
all right; and anxiety because her 5-year-old son is being cared for by her mother-in-law and she thinks that the child
she needs. She refuses to get out of bed because she says it hurts so much that she doesn’t want to
ask the nurse to help her get up, she is afraid of falling.
Sugar levels are at 120mgs. Hgb 12g/dl
Client’s profile:
Occupation: Model
Catholic religion
First intercourse: 15 years
Number of companions: 2
58.
Past history:
She suffered from measles and chickenpox. She reports that she has all the immunizations. In its
family everyone is healthy.
Prenatal history
She visited the doctor 15 times, took prenatal vitamins, and had an amniocentesis.
Birth history:
She underwent a cesarean section, vertical incision, and general anesthesia. The baby weighed 9lbs., Apgar
scores 8-9, medium 21 inches.
Postnatal history
Moderate bleeding, uterus at navel level, clean and dry incision.
Medicines:
Ancef 2 grams every 12 hours for 3 hours
Demerol 75mgs with Phenergan 25PRN
Colace 1 tablet daily h.s.
Milicon 80mgs, daily
Ferrous sulfate 325mgs daily
Laboratories
HgB 12 grams
WBC 10,000
RBC 5.8
Blood Sugar Levels 120mgs
Treatments:
Ringer lactate 1,000 every 8 hours
semi-sitting position
Spirometry three times a day
regular diabetic diet
PRN uterine massage
daily wound care
Intake and Output
59.
Activities she does:
Activities related to your modeling profession
Regular exercise.
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