Post Partum Care Plan PDF

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POST-PARTUM CARE PLAN IMANI ABDULLAH TUSKEGEE UNIVERSITY

TUSKEGEE UNIVERSITY DEPARTMENT OF NURSING NURSING CARE PLAN

Student Name____________________________ Facility: ___________Unit/Area: __________ Instructor: __________________Course: __________ Dates of Care: __________ Assessment (25pts)

Nursing Diagnosis (15pts)

Planning (25pts)

Interventions(20 pts)

Gender/ethnicity: Black, Female, A.L. Age: 31 year old Gravida: 1 Para: 1 Gestation: 38 weeks 4/7 days Vitals: T: 98; HR: 103; R: 19; BP: 131/85 Medications:  Percocet 5/325 PRN pain Antepartum  O+  Meds taken during pregnancy: multivitamin, iron  OB hx, complications o Hx of uterine fibroids o Myectomy 2018  NKA  Immune to Rubella Labor  Continuous fetal monitoring showed no signs of fetal distress  Mother received spinal anesthesia, no labor complications Delivery  Induced labor due to hx. Of fibroids hypertension  Delivery via C-section  Delivery: 3/25 @ 9:13  Transverse Cesarean incision  Estimated blood loss: 500 ml.  Admission Hgb: 10.9

1. Risk for infection RT Csection AEB transverse cesarean incision, obesity, and urinary catheter

1. During the 1500-2100 pt. will show no signs of infection and understand the primary prevention method.

A. During the 1500-2100 TUSN will teach the importance of handwashing. (T)

A. Transmission of microorganisms can be prevented by performing adequate hand hygiene. (Lowdermilk, 2016)

B. During the 1500-2100 shift the will monitor for elevated temperature.

B. Bacteria grow in a warm moisturized area to help them colonize and start an infection. (Lowdermilk, 2016)

C. During the 1500-2100 shift, TUSN will monitor the bands and White Blood Cell count and urinalysis. (M)

C. An elevated White Blood Cell Count indicates a sign of infection as well as nitrates in the urine. (Lowdermilk, 2016)

A. By the end of the 1500-2100 hr shift, the mother will indicate and perform a return demonstration on the proper position of an infant in a car seat. (T)

A. Placing infants on their back prevents Sudden Infant Death Syndrome (Lowdermilk, 2016).

B. During the 1500 to 2100 hr shift, the mother will be able to identify authorized personnel to care for her newborn. (P)

B. Mothers should be aware of anyone present in their room caring for their newborn to prevent infant abduction. (Lowdermilk, 2016)

C. During the 0645 to 1400hour shift, the mother will be able to demonstrate the position safest for her newborn to. (T)

C.In a car, infants are rear facing up until they are 2 years old or reach the maximum weight required by that particular seat. (Lowdermilk, 2016)

2. Knowledge readiness RT to infant car seat and sleeping safety AEB needing specific teaching

3. Acute pain r/t C-section

2. During the 1500-2100 the mother will be able to identify 3 ways to keep her infant safe.

3. During the 1500-2100

A. TUSN will administer

Rationale (5)

A. Early intervention with

Evaluation (10 pts) Goal met – pt. exhibited no signs of infection and verbalized proper handwashing technique and the importance of

Goal Met – Mother identified back to seep method and how to properly place the infant in the car seat and how to properly buckle the car seat into the car

Goal met – mother reported pain on a scale of 2 on a scale of 1-10

 Postpartum Hgb: 9.3 Family (mother) – infant interaction  Mom wants to provide the best parenting possible to baby but has no concerns  Excited to have delivered a healthy baby girl Communication  Mom holds baby close to body  Mom shows interest in her newborn but allows mother take over care  Mom consoles the newborn when she cries Infant needs  Mother needs more information on infant safety (car seat, sleeping) Gender/ethnicity: Black, female Age: 1 day old Overall appearance  Awake and alert  Strong cry at birth  Arms and legs are flexed  Apgar 1: 8  Apgar 2: 9 Measurements  Length: 18in.  Weight: 6lb, 3oz.  Characteristics  Breastfeeding and bottle feeding  Lose nuchal x 1

incision AEB facial grimacing when changing position and verbalization of pain 10/10.

shift, pt. will report a decrease in pain at 3 or less on a scale of 1-10.

PRN opioid pain medication B. TUSN will teach pt. nonpharmaceutical ways of reducing pain such as guided imagery and soothing music. C. TUSN will provide a cold compress for the incision site.

pain medication can decrease the amount of opioid needed to control pain (Lowdermilk, 2016) B. These techniques help to reduce stress and tension in the patient that can influence pain (Lowdermilk, 2016) C. A cold compress is helpful in reducing pain levels and inflammation to surgical sites (Lowermilk, 2016)

References Lowdermilk, D. L., Perry, S. E., Cashion, K., & Alden, K. R. (2016). Maternity & Womens health care. St. Louis, MO: Elsevier

Grading - Nursing Care Plan Student_________________________________

Dates of Care ______________________________

Facility _________________________

Instructor__________________________________

Area

Points Possible

Assessment

25

Nursing Diagnosis

15

Planning

25

Interventions

20

Rationale

5

Evaluation

10

Total

100

Points Achieved

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