NRG5000 Theoretical Foundations of Nursing: Care Plan

NRG5000 Theoretical Foundations of Nursing: Guidelines for Nursing Process: Maternal Nursing Patient Care Plan…

NRG5000 Theoretical Foundations of Nursing

Dr. Lisa Capps, Faculty

Guidelines for Nursing Process: Maternal Nursing Patient Care Plan

Nursing Diagnosis:

Nursing diagnosis consists of the diagnostic label, “related to” and the “as evidence by” components.

A “Risk for…” diagnosis does not have “as evidence by”.

Diagnostic label: Is selected from the NANDA International Diagnosis.

“related to” the condition or etiology of the problem the patient is experiencing.

“as evidenced by” assessment data that supports diagnosis

Assessment as evident by (AEB), or data collection relative to the nursing diagnosis	Outcome (objective, expected or desired outcomes or evaluation parameters	Interventions/Implementations/SHOULD HAVE RATIONALE FOR EACH INTERVENTION	Evaluation(Each OUTCOME needs an evaluation statement)
Assessment supports the nursing diagnosis above. The assessment should reflect the “defining characteristics” that are expected to be present for that diagnosis to be appropriately utilized.Types of data: subjective & objectiveSources of dataNursing health historyPhysical examinationDiagnostic data	The OB care plan will focus on short term outcomes.“What do you/your patient want to achieve today? …at next assessment?”Should be acceptable by the patient and the nurse, realistic, specific and measurableStated realistic behavioral terms that can be observed, measured and relevant to the identified nursing diagnosis.	Intervention –The planned nursing actions that are likely to achieve the desired outcomesInterventions should reflect on going assessment and activities that will assist in achieving the goal/outcomes.Interventions should reflect independent nursing practice as well as collaborative practice.Interventions should reflect the needs of this specific patient not a generic listing of possible interventions.Interventions should include specifics like schedules, food choices, frequency, etc….Rationales- reasoning behind your choosing the intervention; scientific explanation and/or underlying reason for which the intervention was chosen for your patient

Nursing and the Care of Childbearing Families

Student Name: Gladys Mireku Date of Care: 10/9/2022

Focus of Care Plan: (highlight one) Labor/Birth Postpartum Newborn

Identifying information : Complete information section for MOTHER on Labor Care Plan

Complete information sections for MOTHER and NEWBORN on Postpartum and Newborn Care Plan

MOTHER Initials: K.H Gravida 1 Para 1 (4-digit Parity) EDC: 10/1/2022 Gestational age: 39 weeks

Abnormal prenatal test results: None QBL 300 Blood Type: A positive Type of anesthesia used during labor and/or birth (if applicable): Patient refused Current Medications: Acetaminophen1000mg, Docusate 1000mg (Colace), Ibuprofen 600mg, Lidocaine 10 mg

Episiotomy or laceration (describe by type and/or degrees: second degree Laceration

NEWBORN Initials: N K Birth date: 10/9/2022 Time of birth: 04:42 Sex: female Gestational age: 5hrs 20 min Birth weight: 3.3kg lbs./7 oz.; 26 grams

Age (in hours): 5hrs 20 minutes APGAR scores at birth: (one minute) 8 (5 minutes) 9 Method of feeding: Breast feeding

Blood type: Not yet known Coombs: Not yet done TCB or TBili: None Glucose: PRN

Additional Information: Complete information below for Labor, Postpartum, and Newborn Care Plans

Type of birth: (circle) vaginal delivery Cesarean-section Vaginal Birth After Cesarean (VBAC) not born yet

Is there history of any high-risk situations or complications during previous pregnancy, labor/birth, or postpartum period? YES: NO: None

If yes, please list:

Is there history of any complications during current pregnancy, labor, birth, postpartum, or newborn? YES: NO: None

If yes, please list: ________________________________________________________________________________________________________

Nursing Diagnosis: (include all 3 components): Diagnosis Pain R/T A second degree laceration ASB Second degree tear

Assessment or data collection relative to the nursing diagnosis(provide subjective and objective assessments)(This is your assessment of your patient)	Patient Outcome (objective, expected or desired outcomes or evaluation parameters)INCLUDE 2 COUTCOMES(S-M-A-R-T)	Interventions/Implementations and Rationale(specific nursing actions- MUST include a rationale with each intervention)(INCLUDE at LEAST 3 INTERVENTIONS AND RATIONALES)	Evaluation(include whether outcome was met, partially met or unmet)If the outcome is “unmet” what is your plan to meet outcome in the future?
	Outcome #1:	Interventions and Rationales for Outcome #1:1.)2.)3.)	Evaluation for Outcome #1:

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Outcome #2:

Interventions and Rationales for Outcome #2:1.)2.)3.)

Evaluation for Outcome #2: