Care P

Student Name:

Week:

Dates of Care:

Focus of Care Plan: Labor / Postpartum / NB

(highlight area of focus)

Patient Initials

M.Z.

Sex

F

Age

29 y/o

Room

1176

Admitting Date

11/18/20

Reason for Admission:

Delivery

Attending physician/Treatment team:

George L. Stan

Consults during hospitalization:

Ehimiaghe, Eseohi MD

Present Diagnosis: (Why patient is currently in the hospital)

ER Management: (if applicable)

Allergies:

NKDA

Code Status:

Full (No ACP forms)

Isolation: (type and reason)

Contact Precaution

Droplet Precaution

Admission Height:

Admission Weight:

Pre-pregnancy BMI:

Arm Band Location (colors & reasons)

Communication needs: (verbal, nonverbal, barriers, languages)

N/A

Past Medical History: (pertinent & how managed)

Hypothyroidism

Significant Events during this hospitalization: (include date, event and outcome)

Tests/Treatments/Interventions impacting clinical day’s care: (include current orders)

Year

Week gestation

Outcome (SAB, IAB, NSVD, C/S)

Sex of Infant

Complications to pregnancy, labor/birth, or postpartum

HEALTH ASSESSMENTS Postpartum or Labor: depending on focus of care plan

Assessments and interventions: (Include all pertinent data)

Vital signs: (2 sets per day)

Gastrointestinal Assessment and Interventions:

S/O:

Diet:

Interventions:

Respiratory Assessment and Interventions:

S/O:

Interventions:

Neurosensory Assessments and Interventions:

S/O:

Interventions:

Cardiovascular Assessments and Interventions:

S/O:

Interventions:

Musculoskeletal Assessment and Interventions:

S/O:

Interventions:

Renal Assessment and Interventions:

S/O:

Intervention:

Skin Assessment and Interventions:

S/O:

Intervention:

Pain Assessment and Interventions:

S/O:

Pain score:

Assessments/Interventions:

(scale used, location, duration, intensity, character, exacerbation, relief, interventions)

Vascular Access: (IV site) Assessment and Interventions:

S/O

Assessments/Interventions: (include type of fluid & access, location, dressing, date inserted, tubing change)

Endocrine Assessment and Interventions:

S/O:

Intervention:

Post-operative /procedural: Assessment and Interventions:

S/O:

Intervention:

Safety:

S/O:

Interventions:

Advance Directives/Ethical considerations:

Psychosocial Assessment/Interventions: (mental illness, social history, living arrangements, primary care giver, substance abuse, maternal/infant bonding, family dynamics)

Cultural/Spiritual Assessment and Interventions: (religious preference, adaptations & modifications, end of life decisions)

Growth & Development Assessment and Interventions: (physical, psychosocial, cognitive, moral, spiritual using various theorist) What stage of development evident with patient:

Postpartum Assessment:

(for PP care plan only)

B:

U:

B:

B:

L:

E:

L:

E:

Current Plan of Care: (summarize the anticipated plan of care for mother or baby, depending on the focus of the care plan)

Discharge Plan: (Briefly state when, with whom, and to where the patient anticipates being discharged)

Teaching needs: (Identify the teaching needs for this mother and/or family; bullet points OK)

PLEASE NOTE: The physiology/pathophysiology discussion should be in the student’s own words. Cite the source of the information using APA format.

Normal Physiology Discussion: (All care plans must have a brief discussion of the normal physiology related to their specific patient. (Examples: Discuss what is happening physiologically during labor and birth. Describe normal postpartum physiology. Discuss newborn physiology immediately following and in the first hours after birth.)

Pathophysiological Discussion: (If your patient is experiencing a pathophysiological disease process please address at the cellular level (in your own words). Explain why this patient is encountering this particular health deficit. What is the relationship of this current health alteration to the patient’s other medical conditions? Describe the current disease process the patient is encountering: etiology, epidemiology, pathophysical mechanism, manifestations and treatment (medical and surgical). Also note the complications that may occur with these treatments and the patient’s overall prognosis. (Include appropriate references and use APA format.)

Priority

Nursing Diagnosis

Related to

As Evidence By

Rationale (reason for priority)

1

2

3

Medications

Classification

Dose, Route, Frequency

Purpose/Mechanism of Action (Why is THIS patient on this medication?)

Significant Side Effects/ Adverse Reactions (related to THIS patient)

Nursing Implications

Acetaminophen

(Tylenol)

Benzocaine

20% spray

1 Spray

Biscacodyl

(DULCOLAX)

Suppository

Diphenhydramine

tab

(BENADRYL)

Colace

Assessment or data collection relative to the nursing diagnosis

(provide subjective and objective assessments)

Patient Outcome (objective, expected or desired outcomes or evaluation parameters)

(S-M-A-R-T)

Interventions/Implementations and Rationale

(specific nursing actions- MUST include a rationale with each intervention)

Evaluation

(include whether outcome was met or unmet)

If the outcome is “unmet” what is your plan to meet outcome in the future?

Assessment or data collection relative to the nursing diagnosis

(provide subjective and objective assessments)

Patient Outcome (objective, expected or desired outcomes or evaluation parameters)

(S-M-A-R-T)

Interventions/Implementations and Rationale

(specific nursing actions- MUST include a rationale with each intervention)

Evaluation

(include whether outcome was met or unmet)

If the outcome is “unmet” what is your plan to meet outcome in the future?