Quote from sn07
Can anyone give a suggestion for a nursing diagnosis and care plan for a rather traditional vaginal delivery(no problems). I was thinking of something with breast feeding because this is a first time mother and both she and her husband were concerned that the baby wasn't getting anything. Although I explained to her that it is normal for the baby to sleep a lot the first 24 hours after birth, they were still concerned. Every time she put baby to breast she would latch on, take a few sucks and then fall asleep again. This is due by tomorrow morning so any suggestions would be of great help. Thanks for all replies in advance! I actually need 2 full plans so any thoughts would be greatly appreciated. Guess I should purchase a care plan book specifically for maternity!
look at diagnoses dealing with hydration, risk for hyperbilirubinemia, and breastfeeding. Start with a diagnosis, move from there using ADPIE. babies do sleep a lot the first day but they have to eat at least Q6h, and more often if they are breastfed, LGA, SGA, or infant of diabetic mother. Generally its Q 2-4h for breast, and Q3-4h for bottle at my facility.
What did you do to help mom get the baby to wake up? What else could you do? Those would be implementations for your care plan.
Also look at mechanical things that would have impeded breastfeeding, such as flat nipples, tongue sucking, cleft palate, inverted nipples, etc. If anything mechanical is there, then think what you would do to solve the problem.
If the delivery went well, look for your 'risk for' diagnoses. What is a mother at risk for? What are her risk factors, and what can you do? If she had a precipitous birth, or has had many children, or is a VBAC then she is a hemorrhage risk. If she is breasfeeding she is risk for breast engorgement, pain, mastitis/infection. What would you do? Again use ADPIE, and you will find your careplan.