First of all, did you try to attach some files? If so, they didn't come across as active links--at least not on my computer.
When you are working on care plans you have to remember that a care plan is a written expression of the nursing process. The steps of the nursing process are (you should be able to recite these in your sleep):
- Assessment
- Nursing Diagnosis
- Planning
- Implementation
- Evaluation
The steps of the care plan process are:
- Assessment (collect data)
- Formulate Nursing Diagnoses
- Write measurable outcomes and interventions
- Initiate the care plan
- Determine if outcomes have been met
Formulating nursing diagnoses is based on the assessment data you have collected. If your data is lacking, then your diagnoses will fall short. That's is why it is imperative to have a good assessment guideline or tool to use in assessing the patient. So, your mom is in her third trimester and here are some of the things that your assessment should be addressing in the third trimester:
- her discomforts and her methods of dealing with them (you mention that she has times of intermittent dull, low back pain. How does she deal with the pain? Was this affecting her gait in any way?)
- assess respiratory status
- leg cramps
- Braxton Hicks contractions
- paresthesias of toes or fingers
- urinary frequency or bladder pressure
- constipation
- heartburn
- leukorrhea or vulvular pruritis
- any diaphoresis
- patient's familiarity with normal physical and physiological changes associated with the third trimester including the signs of the onset of labor, when to leave for the hospital and the stages of labor
- What was the plan of birth?
- What was the plan of care for the infant after birth?
- Were childbirth and child care classes completed?
- Any sleep or fatigue problems?
I would like to suggest that you have a very real symptom of back discomfort that you should address and place in priority ahead of the knowledge deficit.
Acute Pain R/T physical changes of pregnancy AEB patient report of intermittent dull, low back pain of 3/10
OR
Impaired Comfort R/T physical changes of pregnancy AEB patient report of intermittent dull, low back pain of 3/10
(NOTE: this is not an official NANDA approved nursing diagnosis, however it does fit with what your patient has. If you want to use it, check with your instructors to see if it is allowed.)
Some of your interventions might include things like suggesting the use of shoes with low heels, use of a heating pad, massages by her partner, and the avoidance of prolonged standing and sitting.
If you are to use NANDA language you would re-word your other diagnosis to read:
Knowledge Deficit regarding natural progression of pregnancy R/T lack of information AEB patients report of decreased fetal movements and that the baby has been quiet today
OR
Readiness for Enhanced Knowledge regarding natural progression of pregnancy R/T lack of information about normal pregnancy AEB patient statements expressing an interest in learning
All nursing diagnoses are based on information you have gotten from your assessment of the patient. Therefore, it is absolutely important that your assessment data is as comprehensive and as thorough as you can make it.
You might also want to go through the information about the assessment and the care plan process on these threads:
Hope this information has been of help.
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