Nursing Care Plan (84/56) -- My Academic Journey

Nursing Care Plan Student(s) Name: Uvbi Osatohangbon Date: 11/17/2023 Medical Diagnosis: Uterine Prolapse | Assessment Data | Nursing Diagnosis and Related Goals | Nursing Interventions and Rationale | Evaluation | | Mother BP – 127/80 SPO2 – 97 T – 36.9 HR – 82 Regular R – 16 Soft Abdomen Breath Sounds Clear U/2 fundus Bowel sounds active X4 but Hypoactive Lochia Rubra a little soreness and an hemorrhoid on 2nd degree tear that was repaired RH + GBS – MMR – immune Medications – Pain o Ibuprofen o Morphine – Postpartum hemorrhage o Oxytocin o Carboprost (Hemabate) o Misoprostol – Nausea/vomiting o Dimenhydrinate – Hemorrhoids o Hydrocortisone-zinc History IBS (irritable bowel syndrome) G – 2 T -1 P – 0 A – 1 L – 1 Baby Resp – 44 Temp – 36.7 HR – 144 Bilimeter – 50 Birth weight – 3800 g Day 1 – Voided X 2 – Bowel movement X2 | Risk for constipation related to hypoactive bowel sounds and history of IBS. Risk for impaired skin integrity related to soreness and hemorrhoid. Goal #1 – Short-term: Mother will report being able to have a bowel movement with no problems by a week Goal #2 – Long-Term: Patient will show no signs or worsening signs of soreness, hemorrhoids or irritation by 3 months. | Nursing Interventions – Administer stool softeners or laxatives that have been prescribed – Encourage diet in high fiber – Increase fluid intake – Use prescribed medicated creams or ointments. – Assess skin area regularly – Educate patient on avoidance of excessive wiping or rubbing of affected area Rationale – Can assist in instantiating the first bowel movement for short term use only – Helps maintain bowel health and softens stool – helps to soften your stool – will help treat affected area – will help detect any worsening or improving sign and symptoms. – Help patient prevent worsening sign and symptoms. | Short Term – Not met, unable to evaluate. Long term –I will not be able to evaluate success of this goal as there will be no way for me to evaluate in 3 months. | References Mayo Clinic Staff. (2021, January 6). Dietary fiber: Essential for a healthy diet. Mayo Clinic. https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/fiber/art-20043983#:~:text=Dietary%20fiber%20increases%20the%20weight NANDA International & Herdman, T. H. (2021-2023). NANDA International Nursing diagnoses: Definitions and classification 2012-14. Wiley Blackwell.