NRG5000 Theoretical Foundations of Nursing
Dr. Lisa Capps, Faculty
15
2021 NUR4545: Maternal Nursing Care Plan Assignment
Student Name: |
Week: |
Dates of Care: |
Focus of Care Plan: Labor / Postpartum (highlight area of focus) |
Patient Initials NC |
Sex F |
Age 33 |
Room 221 |
Admitting Date |
Reason for Admission: LABOR |
Attending physician/Treatment team: |
Consults during hospitalization: |
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Present Diagnosis: (Why patient is currently in the hospital) |
ER Management: (if applicable) |
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Allergies: NO KNOWN |
Code Status: FULL |
Isolation: (type and reason): NONE |
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Admission Height: 5’2 (157.5 cm) |
Admission Weight: 182 lbs Pre-pregnancy BMI: 33.28 |
Arm Band Location (colors & reasons) Right hand |
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Communication needs: (verbal, nonverbal, barriers, languages) |
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Past Medical History: (pertinent & how managed) POST DEPRESSION |
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Significant Events during this hospitalization: (include date, event and outcome) |
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Tests/Treatments/Interventions impacting clinical day’s care: (include current orders) |
Reproductive history:
Gravida: Para: T (Term): P (Preterm): A (Abortions): L (Living):
Year |
Week gestation |
Outcome (SAB, IAB, NSVD, C/S) |
Sex of Infant |
Complications to pregnancy, labor/birth, or postpartum |
History of current pregnancy: (Postpartum and Labor Care Plan)
LMP: EDD:
Gestation age:
Total number of prenatal visits:
Complications or risk factors during current pregnancy:
Prenatal education: (if yes, describe type; for instance: class, book, online…
History of current labor and birth:
Onset of labor (date, time):
Rupture of membranes (date, time): Color of fluid:
Delivery date and time: Weeks gestation:
Delivery type: Newborn weight:
Total length of labor:
Fetal presentation at delivery:
Episiotomy and/or laceration (describe by type and/or degree):
Estimated blood loss:
Anesthesia type (epidural/local/IV/none):
Labor complications:
Newborn History: (for Postpartum Care Plan)
Gestation age by dates:
Gestation age by exam:
Birth weight:
Length:
Head circumference:
Chest circumference:
Blood type (if done):
Delivery date & time:
Delivery type:
1 minute APGAR score:
5 minute APGAR score:
Method of Feeding:
HEALTH ASSESSMENTS Postpartum or Labor: depending on focus of care plan Assessments and interventions: (Include all pertinent data) |
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(for PP care plan only) B: U: B: B: L: E: L: E: |
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S/O: Interventions: |
S/O: Interventions: |
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S/O: Diet: Interventions: |
S/O: Interventions: |
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S/O: Interventions: |
S/O: Intervention: |
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S/O: Intervention: |
S/O: Intervention: |
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S/O: Pain score: Assessments/Interventions: (scale used, location, duration, intensity, character, exacerbation, relief, interventions) |
S/O Assessments/Interventions: (include type of fluid & access, location, dressing, date inserted, tubing change) |
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S/O: Intervention: |
S/O: Intervention: |
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Normal Physiology Discussion: (All care plans must have a brief discussion of the normal physiology related to their specific patient. (Examples: Labor care plan: Discuss what is happening physiologically during labor and birth. Postpartum care plan: Describe normal postpartum physiology.) Pathophysiological Discussion: (If your patient is experiencing a pathophysiological disease process please address 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 general health? 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.) |
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2
List of nursing diagnoses (NANDA format). Place diagnoses in priority order and provide rationale for priority setting.
Priority |
Nursing Diagnosis |
Related to |
As Evidence By |
Rationale (reason for priority) |
1 |
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2 |
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3 |
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Significant Side Effects/ Adverse Reactions (related to THIS patient) |
Nursing Implications |
Nursing Diagnosis: (include all 3 components) ___________________________________________________________________
Assessment or data collection relative to the nursing diagnosis(provide subjective and objective assessments) |
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? |
Nursing Diagnosis: (include all 3 components) ____________________________________________________________________
Assessment or data collection relative to the nursing diagnosis(provide subjective and objective assessments) |
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? |
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