Sunteți pe pagina 1din 10

EDYTH T.

JAMES DEPARTMENT OF NURSING

NURS 378 Maternal Child and Women’s Health Nursing

POSTPARTUM CARE PLAN

Student Name: Uche Edwards-Shahid Date: 02/20/2019

Student Requirement: Complete all of the information below for each patient cared for during the
clinical rotation day, by consulting the patient record on the assigned unit. The initial information
gathered will be hand written. Please TYPE and submit at the start of the next clinical.

Maternal History:
Age: 28
GTPAL: G1 T 1 P 0 A 0 L1
11001
EDC: 02/10/2019

Blood Type: 0-
0-
Delivery Date: 02/20/2019

Type of Delivery: Virginal Delivery

Weeks' Gestation: 40
40
Significant Labs: N/A
Pregnancy Complications: Low Birth Weight

Complications in Labor None


/Delivery affecting the
neonate:

Length of Labor: 12
First/Second/Third Stage:

NURS378 Postpartum Care Plan, Revised 12-20-2017 ~~ Professor Persaud pg. 1


EDYTH T. JAMES DEPARTMENT OF NURSING

NURS 378 Maternal Child and Women’s Health Nursing

POSTPARTUM CARE PLAN

Medications used in Epidural


Labor/Delivery:

Language: English

Significant History: N/A

Postpartum Assessment (BUBBLE HHE):


Breast:
Smooth and full
Uterine fundus/Incision:
None
Bowel:
Bowel sounds in all quadrants
Bladder:
Non -Distended
Lochia:
Slight and light
Episiotomy/Laceration/Tear:
None
Homan’s Sign/Edema: None

Hemorrhoids: None

Emotional stable

PATIENT PHYSICAL ASSESSMENT


Jarvis pages 814 -827, 107-11

General Survey: Mental Status (ABCT:


Appearance/Behavior/Cognition/Thought

NURS378 Postpartum Care Plan, Revised 12-20-2017 ~~ Professor Persaud pg. 2


EDYTH T. JAMES DEPARTMENT OF NURSING

NURS 378 Maternal Child and Women’s Health Nursing

POSTPARTUM CARE PLAN

process):

Skin: Intact pink Neurologic:

Mouth: Pink mucosa Neck: No lumps,

Heart: S1, S2, RRR Blood Pressure:


110/66
Lungs: Clear Breasts: Smooth, and tender

Peripheral vasculature (Extremities): No edema Pelvic Exam (Stage of Labor): Transition

Abdomen (Leopold’s Maneuvers/Fetal Heart Non-distress


Tones):

HUMAN NEEDS ASSESSMENT

Data:(Assessment findings, test results, Analysis: (What does the data Nursing Dx (NANDA)
drugs) mean…?) (Actual or potential
problem
Oxygenation: Patient is relatively in good Readiness for enhanced
Vital signs: health health management
T___99.0___P_80___R__18_BP___110/66
_

Hgb__14.0__HCT_37___O2Sat__99__

ABGs: PH 7.35 PCO2 55 PO2 80


HCO26

NURS378 Postpartum Care Plan, Revised 12-20-2017 ~~ Professor Persaud pg. 3


EDYTH T. JAMES DEPARTMENT OF NURSING

NURS 378 Maternal Child and Women’s Health Nursing

POSTPARTUM CARE PLAN

Lung Sounds: clear Oxygen therapy:0

Heart Sounds: Normal

Fluids/Electrolytes: Patient has a balanced Readiness for enhanced


Na:136 K: 4.8 Ca: 8.8 homeostasis nutrition

Intake: 900ml Output:800ml

Nausea/vomiting: None

NPO: None IVs None

Elimination: Patient is relatively in good No risk at this time


BUN: 10 UA Output: none health, ready for nursing her
baby
Urine Character: clear, no odor

Last BM: 02/18/2019

Nutrition: Patient is good in health. Readiness for enhanced


Ht: 5'6 Wt: 150 Every lab result is WNL breastfeeding
Supplements: 0

Blood Glucose: 120 Albumin:


7.0

Hemoglobin: 12.0
Hct:37

NPO: N/A TPN: N/A


Type of diet: Regular Total shift
Intake: Moderate

NURS378 Postpartum Care Plan, Revised 12-20-2017 ~~ Professor Persaud pg. 4


EDYTH T. JAMES DEPARTMENT OF NURSING

NURS 378 Maternal Child and Women’s Health Nursing

POSTPARTUM CARE PLAN

Data:(Assessment findings, test Analysis: (What does the Nursing Dx (NANDA)


results, drugs) data mean…?) (Actual or potential
problem
Rest/Comfort: Patient needs pain medication Readiness for enhanced
for post- partum discomfort
Pain: Location: ABD Quality: from pushing the baby. The
Cramp body is sore

Severity: 6 Duration:
45min
(on a scale 0-10)
Sleep: No sleep issues. Readiness for enhanced
Normal Hours of Sleep: 8 sleep

Duration: N/A

Mobility: No problem with self-care Readiness for enhanced


Activity Level: Ambulates self and ambulation mobility, selfcare

Activity Tolerance: To and from


Bathroom

Spiritual Integrity: Patient is a dedicated Readiness for enhanced


Religion: Christian, Catholic by Christian catholic spiritual growth
affiliation

Beliefs impacting health status:


None
Affiliation: Patient has support of family Readiness for family
Primary Care Provider/support at dynamics progress/
Home: Yes coping

Family Dynamics: Husband, Mother


in law

NURS378 Postpartum Care Plan, Revised 12-20-2017 ~~ Professor Persaud pg. 5


EDYTH T. JAMES DEPARTMENT OF NURSING

NURS 378 Maternal Child and Women’s Health Nursing

POSTPARTUM CARE PLAN

Language Spoken: English

Social worker/case manager:

Community resources: N/A

Sexual Integrity: Patient has a healthy family Readiness for enhanced


Development status: N/A relation family relationship

Reproductive organs: Intact

Relationship with significant other:


good

Data:(Assessment findings, test Analysis: (What does the Nursing Dx (NANDA)


results, drugs) data mean…?) (Actual or potential
problem r/t to patient’s
status)
Safety: Patient is ready not be Readiness for discharge
WBC: 10,000 C & S: discharged home. Patient
manage alright
Vital signs: WNL

Wounds/Incisions: None

Hygiene needs: Self care

Perineal laceration/episiotomy:
None

Pain medications: TYLENOL PRN

Lochia: Slight to none

Hemorrhoids: None

Sensation/Perception/Cognition: Patient is cognitively aware Readiness for enhanced


and functioning communication

NURS378 Postpartum Care Plan, Revised 12-20-2017 ~~ Professor Persaud pg. 6


EDYTH T. JAMES DEPARTMENT OF NURSING

NURS 378 Maternal Child and Women’s Health Nursing

POSTPARTUM CARE PLAN

Orientation: AAOX4

LOC: Intact

Neuro Assessment: Normal

Other Findings: None

Self-esteem: Patient has a healthy self- Readiness for enhanced


Emotional status: Stable awareness and assurance comfort
Mood: Good
Behavior: Appropriate
Appearance: Groomed

Select the TOP THREE human needs and formulate a nursing diagnosis for one. Write
goals and at least FIVE NURSING INTERVENTIONS AND RATIONALES to
accomplish the goal for the nursing diagnosis. (Must cite either Lowdermilk/Perry or
Hockenberry stating “I will ...” or “The student nurse will ...” and must relate to the
Human need and the goal):

1. I will love to get a complete breakfast


2.I will like to go home and sleep in my own bed
3.I will appreciate a good hot cup of coffee

Nursing Outcomes/Goals Nursing Rationales Evaluation (goal


Diagnoses Interventions met or not met?)

NURS378 Postpartum Care Plan, Revised 12-20-2017 ~~ Professor Persaud pg. 7


EDYTH T. JAMES DEPARTMENT OF NURSING

NURS 378 Maternal Child and Women’s Health Nursing

POSTPARTUM CARE PLAN

Readiness for Make sure there are no Monitor mother Nothing to set Goal is met
enhanced unexpected set backs and baby to back the
comfort make sure they progress made
The PCP needs to set up a are progressing towards
discharge plan as soon to discharge discharge of
possible patient and child
Check up on the lab results
to make sure there are
surprises

Mother and baby are doing


fine

No unexpected set backs


such as complications from
delivery

Medications:
Medications Dose/Brand/Generic Indication Route Frequency Side effects and Nursing
names of use Adverse Effects Considerations

TYLENOL 325 2 tabs PRN Pain Oral PRN Bleeding Must not take more
reducer than PCP prescribed

NURS378 Postpartum Care Plan, Revised 12-20-2017 ~~ Professor Persaud pg. 8


EDYTH T. JAMES DEPARTMENT OF NURSING

NURS 378 Maternal Child and Women’s Health Nursing

POSTPARTUM CARE PLAN

IV Fluids:
Type of IV Fluids: Rate Frequency Indications of use

None N/A N/A N/A

Treatments and Procedures:


Treatments and Procedures Date & Times Reason for Tests or Procedures

Pain 02/20/2019 Pain management


@9:00

Evaluation of mastery of objectives set for the day (Was the Goal met or unmet? If yes, how?
If not, why not and how can you meet or modify the Goal?):

NURS378 Postpartum Care Plan, Revised 12-20-2017 ~~ Professor Persaud pg. 9


EDYTH T. JAMES DEPARTMENT OF NURSING

NURS 378 Maternal Child and Women’s Health Nursing

POSTPARTUM CARE PLAN

Yes

Areas for professional growth (the student’s):

Need to pay more attention to the medical terms and usage of proper terminologies for effective
communication and documentation

NURS378 Postpartum Care Plan, Revised 12-20-2017 ~~ Professor Persaud pg. 10