Hi I am doing a care plan for an OB class and I am having difficlty with it .

This is my patients history :The patient is 37 weeks gestation. She has spontaneous rupture of membrane. She has a history of endometriosis, she did LEEP. They augment her labor. She is positive for HBV. She had a previous Episiotomy for her first child.


I came up with two diagnosis the first is my priority

1. Risk for infection related to spontaneous rupture of membrane as evidenced by vaginal examinations

Short term goal 1: Patient will reatain normal vital signs
Short tern goal 2 :Patient will verbalize an understanding of the risk factors for infection during labor and delivery
Long term goal: Patient will show no signs of infection throughout hospitalization.

For the second diagnosis : I choose Chronic pain related to inflammation and adhesions of endometrial tissue as evidenced by patient reporting pain as 7 on a scale of one to ten and requesting epidural

short term goal 1: Patient will state a decrease level of pain within 2 hours of pain medication using 1-10 pain scale.

Short term goal 2. I cant come up with one for this

Longterm goal: Upon discharge, the patient will lean to manage her pain effectively with the use of pharmacological and non-pharmacological pain relief strategies

Please say if i am on the right track and what am I doing wrong