help me, I need an NCP (nursing care plan) for this. your help would be very much appreciated, thank you!
Patient Mrs. M went to the clinic for check – up for the first time. Her chief complains revealed that she was having nausea and vomiting every after breakfast. The Obstetrician ordered her to eat crackers and eventually advised her to observe for its progression. Upon examination, the Obstetrician observed her tummy with a dark line and her face and neck with melasma. The patient also told the OB that her legs were feeling heavy and she feels tiresome at the end of the day. She further reported that she experiences frequent urination and oftentimes she’s constipated. She was then advised to have her regular check-ups. The following data were taken from the patient’s profile which showed the following:
Name of patient : Mrs M
Age: 27 years old
Occupation: housewife
OB Score : G3P2
LMP : 2/03/2010
EDD : 11/10/2010
2 days after Mrs. M had her first clinic visit, she was admitted to the hospital. Date of Admission: 11/12/2010 @ 6:30PM. The following data were taken from her as follows:
Mrs. M. is a 27-y/o gravida 3, para 2, who was admitted at term at 6:30 p.m. She stated that she had been having contractions at 7 to 10 minute intervals since 4 p.m. They lasted 30 seconds. She also stated that she had been having "a lot of false labor" and hoped that this was "the real thing". Her membranes were intact. Mrs. M.'s temperature, pulse and respirations were normal and her blood pressure was 124/80. The fetal heart tones were 134 and regular. The nurse examined Mrs. M. and found that the baby's head was at +1 station, and the cervix was 4 cm. dilated and 80 percent effaced. She reported her findings to the doctor and he ordered Demerol 50 mg. with Phenergan 25 mg. to be given intravenously when needed
The doctor gave her a pudendal block and did a midline episiotomy. At 8:05 p.m. Mrs. M. gave birth to a 7 lbs., 5 oz. (3.317 gm.) boy in the L.O.A. position. The nurse put medicine in the baby's eyes and placed an identifying bracelet on his right wrist and ankle. A matching bracelet was placed on the mother's wrist. The baby was shown to his mother and then taken to the newborn nursery. At 8:08 p.m. the placenta was expelled.
The nurse assigned to Mrs. M documented the following observations
Chief complaints :
- Ammenorrhea for 9 months
- Having labor pain for since 4 PM
- Back ache
Observations of Second stage of labor
- Uterine contraction
- Descent of the presenting part
- Fetal condition
- Maternal condition
Transition from fisrt stage to second stage of labor
- Increasing intensity of uterine contraction
- Appearance of bearing down efforts
- Urge to defecate with descent of the presenting part
- Complete dilatation of the cervix as evidenced on vaginal examination
After the delivery, Mrs M was transferred to the OB Ward and was advised that she observes for profuse bleeding or any untoward signs and symptoms felt. The nurse upon checking noted that Mrs M’s bleeding is not more than 250ml. Occasional change of sanitary napkins were noted. Uterus was at the midline and well contracted. Occasional uterine cramping was also noted. Pain in the suture site was reported. Vital signs are normal. Mrs. M feels thirsty and hungry but can not avail due to exhaustion after the delivery. She said she feels too weak to do things for herself.
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