Care Plan

Nursing and the Care of Childbearing Families

Student Name: Gladys Mireku Date of Care: 10/2/2022

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: M.K Gravida 1 Para 0 (4-digit Parity) EDC: 9/27/2022 Gestational age: 41 weeks

Amniotic fluid Clear (clear or meconium in fluid) Prenatal Group B Strep: Positive Did mom receive antibiotics in labor: Yes

Abnormal prenatal test results: Not Known QBL: Not yet Blood Type: A positive Type of anesthesia used during labor and/or birth (if applicable): Not yet Current Medications: Pitocin, Dilaudid ,Misoprostol

Episiotomy or laceration (describe by type and/or degree):Not yet

NEWBORN Initials’ Birth date: Time of birth: not yet Sex: Female Gestational age: not yet Birth weight Not known lbs./oz. grams

Age (in hours): Not yet APGAR scores at birth: Not yet (one minute), Not yet (5 minutes) Method of feeding: Breast feeding

Blood type: Not yet known Coombs: Not yet known TCB or TBili: Not known Glucose: Not known

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:

If yes, please list:

Nursing Diagnosis: (include all 3 components): Diagnosis Pain R/T__________ASB_________________________

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: