3132-28_ApdxBrev.qxd 12/15/05 3:47 PM Page 772
B
Clinical Paths
Labor and Delivery Clinical Path Labor: Expected Outcomes
Active Phase Expulsion/Pushing Recovery 1st Hour Post Partum
Patient coping with labor Patient demonstrates effective Bonding appropriately with baby
support pushing technique.
Patient utilizing appropriate Patient coping effectively with
labor options pushing.
Patient verbalizes satisfaction Support person coping
with plan effectively with labor
Management interventions
Cervix dilated 5 cms-complete Vaginal birth Placenta delivered
Contraction regularly with Fundus firm
progressive cervical change. Lochia small moderate
Maternal/fetal well being Without clots
maintained. Perineum intact/repaired
Hydration maintained. Hemodynamically stable
If indicated: FSE and/or IUPC EBL <500 cc
placed
IV Pitocin started
Epidural placed/WE
encouraged
Medicate with Prn pain meds
Prenatal record available after
32 weeks
Prenatal labs WNL
Pre-registered to hospital
Pediatrician identified
Support after hospitalization
identified
Discharge plan discussed with
patient/family.
Communicates understanding
of hospital and community
resources
appendix
PATIENT
EDUCATION
PATIENT STATUS
CONTINUUM OF CARE
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Appendix B 773
Interventions
Assess: Continuous EFM or Assess: Q 15 minutes Assess: Uterus fundus
auscultation monitoring of fetal well Vital signs
Q 15 of 30 minutes as being (Low-Risk) and Lochia
indicated. Q 5 minutes (High-Risk) Bladder
Vital signs hourly/Temp Q4 hours Vital signs hourly Temp. Q 2 4 Perineum
if intact membranes/Q 2 hrs hrs. depending on Placenta
if membranes ruptured membrane status
Uterine by monitor or palpation Bladder for distention
Bladder for distention Hydration status
Hydration status Pushing effectiveness
Cervical dilation, effacement, Descent of presenting part
station Caput
Reinforce comfort measures Teaching of upright pushing Baby status
Encourage use of labor options positions Breast feeding
Inform patient/support person Discourage prolonged
of plan of care maternal breath holding
Encourage to assume position
of choice
Inform patient of progress
Hgb or Hct (if not done AROM: assess for color, amount Cord blood or Rhogam workup
recently) and odor, as appropriate if appropriate
T & S (if ordered) Cord blood if O+ Mom
VE as indicated
IV therapy
AROM by M.D. or CNM: assess
for color, amount and odor,
as appropriate
FSE/IUPC placement if indicated
Comfort measures/Birthing Perineal massage Ice pack to perineum
ball/ambulate/telemetry/ Warm soaks to perineal area Warm blankets
shower Allow to rest until feels urge
IV therapy to push
Amnio Infusion for Variable Frequent position changes
decelerations Cool cloth/Ice chips
If appropriate, Pain Mgmt.
reviewed.
Antibiotics as indicated for + GBS Pitocin if indicated Pitocin IV
Pitocin if indicated
PRN pain medication
(Encourage WE if
requesting this).
Labor option usage Provide wedge if supine Assist with ambulate to bathroom
Promote effective position for Infant care
Position changes
pushing: ie: squatting, side Assist with positioning for breast
lying, upright feeding
Breathing technique Infant ID bands present
patient/support person most
comfortable with
(continued)
TREATMENT
ASSESSMENT/
PATIENT
TESTS/
PROCEDURES
EDUCATION
THERAPIES
MEDS
SAFETY
ACTIVITY/
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774 Appendix B
Labor and Delivery Clinical Path Labor: Expected Outcomes (continued)
Interventions
Clear liquids Clear liquids Return to previous diet
Ice chips Ice chips
OTHER
Integrated Plan of Care for Cesarean Delivery
Expected Patient Outcomes
Phase 1
Preadmission Phase 2 Surgery/
(Cesarean Immediate Postop/ Phase 3 Post Op
Delivery) Day of Surgery Day 1
Usual time in N/A Date Started: Up to 23 hours 1 day 1 2 days
Phase
Assessment / VS WNL for patient VS WNL for VS. WNL for patient Incision well
Potential Hgb or Hct/values patient Systems Afebrile approximated,
Complications within normal assessment: Voiding without without drainage
SLH antepartum Skin warm, dry, foley ś' or redness
range Clear ś' Passing flatus Passing flatus
Alert & oriented ś' Incision without Lochia sm/mod
Neg. Homan s redness or amt
sign ś' drainage Fundus firm u/1 2
Breast soft/nipples Lochia small amount Verbalizes comfort
intact ś' Fundus firm u/1 2 using pain
Lungs clear ś' Verbalizes comfort medication as
Bowel sounds using pain scale described
present ś' 0 10 on oral pain
Fundus firm u/u or u meds
1 2 (-/+)
Lochia sm mod
Dsg dry and intact
No signs infiltration
IV site
Verbalizes comfort
using pain rating
scale 0 10
NUTRITION
NEEDS
UNIQUE PATIENT
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Appendix B 775
Expected Patient Outcomes
Phase 1
Preadmission Phase 2 Surgery/
(Cesarean Immediate Postop/ Phase 3 Post Op
Delivery) Day of Surgery Day 1
Date All Above Met Date All Above Met Date All Above Met Date All Above Met
Patient / Family Verbalizes verbalizes correct can state criteria Verbalizes follow-
Knowledge understanding use of PCA/ for when to call up appointment
of condition and Fentanyl pump doctor for date and time
need for surgery and when to problems post
Verbalizes proper
request pain discharge ś'
Verbalizes dosing of pain
medication ę! bleeding
understanding medication
ę! Temperature ś'
of all pre-op Turn, Cough &
incision redness,
teaching deep breath
odor or
appropriately
drainage ś'
Date All Above Met Date All Above Met Date All Above Met Date All Above Met
ADL s / Activity Verbalizes Able to ambulate Ambulating without Ambulating in hall
understanding with minimal assistance
of NPO status assistance
Tolerating soft to
Tolerating clear/full regular diet
liquid diet
Bonding observed
with newborn
Taking-in
phase ś'
Date All Above Met Date All Above Met Date All Above Met Date All Above Met
Unique Patient
Needs
Date All Above Met Date All Above Met Date All Above Met Date All Above Met
Entire Phase Entire Phase Entire Phase Entire Phase
Outcomes Met; Outcomes Met; Outcomes Met; Outcomes Met;
Progress patient Progress patient Progress patient Progress patient
to next phase to next phase to next phase to next phase
Plan of Care
# 2 Surgery/
Immediate Postop/ #3 Post Op #4 Post Op Day 2-
#1 Preadmission Day of Surgery Day 1 Discharge
Assessments Vital Signs VS per PACU then VS q 6 hr Assess pain control
q 4 hr Assess pain control 0 10 scale
Fetal status
Systems assessment: 0 10 scale Incision
immediately
*Skin, LOC, FROM, Incision Volding
prior to surgery
Homan s sign, Foley-volding Fundus
*Breasts, Lungs, Fundus/lochia lochia
Fundus, Incision, Homan s sign Homan s sign
*Lochia, bladder, IV site IV site as needed
bowel sounds, Breasts ID band on mother
IV & site ID band on mother Activity
Activity
(continued)
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776 Appendix B
Integrated Plan of Care for Cesarean Delivery (continued)
Plan of Care
# 2 Surgery/
Immediate Postop/ #3 Post Op #4 Post Op Day 2-
#1 Preadmission Day of Surgery Day 1 Discharge
*I & O q shift
*Assess pain control
0 10 scale
*Assess Rhogam
status
*Assess Rubella titer
status
*ID band on
mother
Consults Anesthesia Social Work as Social Work, Social Work,
needed, Lactation, Lactation,
Anesthesia, Dietitian as Dietitian as
Lactation, needed needed
Dietitian as
needed
Patient / Family Need for surgery Review post-op Review dietary Verify follow-up
Education Review Cesarean expectations needs post appointment
Discharge Delivery Review equipment surgery date and time
Planning Review us prn Review Bleeding/ Activity restrictions
procedure, Lochia Follow-up for staple
Instruct pt on:
postop Precautions post removal as
Hospital/Infant
expectations cesarean needed
security systems
Demonstrate/ delivery Offer Home follow-
Unity orientation
Discuss Review follow-up up care
Newborn
equipment care and doctor Discuss birth control
orientation/care
PCA, Fentanyl Appointments
/feeding (if
pump Review incision
breastfeeding
Tour of OR area care, peri care
problems see
& Nsy Infant care
decision trees)
Infant feeding
Tests and PAT; Hgb or Hot (if
Procedures not done
recently within
one month)
T & S (if ordered)
Pharmacologic IV fluids as ordered IV lock DC IV lock as
Needs Pain control: PCA, ordered
PO pain meds
Fentanyl pump,
Give Rhogam if
IM to PO
indicated
Give Rubella if
indicated
3132-28_ApdxBrev.qxd 12/15/05 3:47 PM Page 777
Appendix B 777
Plan of Care
# 2 Surgery/
Immediate Postop/ #3 Post Op #4 Post Op Day 2-
#1 Preadmission Day of Surgery Day 1 Discharge
Activity / Patients usual Change position Progress Ambulate in halls
Rehabilitation q 2 hr while in endurance/ without
bed, OOB stand begin assistance
at bedside post- Ambulation in hall
op night/dangle
OOB in AM
and transfer to
May shower
chair
Progress to pt.
endurance
Observe bonding
with infant
Observe family
support system
(if inadequate
consult SW)
Nutrition / NPO then clear DAT to regular or
Elimination liquids to DAT previous diet at
home
Foley empty q shift
FOLEY DC d
Miscellaneous TCDB q 2 hr while Dressing removed
Interventions awake by MD or RN with
MD request
Unique Patient
Needs
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