Care Plan 2

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

Amniotic fluid (clear or meconium in fluid) Prenatal Group B Strep: positive Did mom receive antibiotics in labor: yes

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: