Problem: Sandy Bliss, a 30-year-old nulliparous woman is in active, spontaneous labor. She plans childbirth without an epidural. The baby begins to experience frequent, deep, variable decelerations, raising concerns that an emergency C-section may be needed. The anesthesia provider evaluates Sandy and determines that the airway is unfavorable, and a difficult intubation is likely if general anesthesia is required. The team discusses the situation, and the obstetrician then speaks with Sandy and they agree that an epidural will be used.
1. Develop a plan of care for your patient
Care plan with Medical diagnosis, Nursing diagnosis, short-term and long-term goals, subjective and objective data, interventions with rationales, and reevaluation outcomes.