a care plan is about determining the patient's nursing problems and then developing strategies to do something about them. the hard part is determining what those nursing problems are. we have the nursing process to help us. the most important part of the nursing process is the assessment. the information that we collect during our assessment activities is what guides our decision making when it comes to diagnosing. we are specifically looking for what is abnormal about them. this is why we learn what is normal when we learn about physical assessment. when someone has a baby certain things happen to the female body that are considered "normal" insofar as childbirth is concerned, yet childbirth is traumatic to the body. how much did this baby weigh? a 5 or 6 pound baby coming though the vaginal canal creates trauma. ask any woman who has had a baby. in the excitement, exhaustion and relief after it is all over the moms forget the pain they went through. however, their bodies don't. tissue trauma did occur. did this mom have an episiotomy? if so, that is a surgical incision that is impaired tissue integrity
. while that baby was coming through the vaginal canal and the tissues of the mom's body were being stretched there were micro tears that you can't see. the body immediately begins to enact the inflammatory response as part of her recovery and that includes the 4 cardinal signs of redness, heat (fever), swelling (may be some bladder problems as a result) and pain (secondary to the swelling). while we're talking about micro tears, any break in skin or mucous membrane is a potential entry point for bacteria, so that is a risk for infection
. did you say this was a 16-year old? what were you doing at 16 at this time of the year? i was going to my prom. what does erikson say a 16 year old should be doing? there are developmental issues here because this is a child having a child. you have, on one hand, the adolescent: identity vs role confusion where the child tries integrating many roles (child, sibling, student, athlete,worker) into a self-image under role model and peer pressure. they transition into the young adult: intimacy vs isolation where they learn to make personal commitment to another as spouse, parent or partner. certainly this young lady may have some role identity issues. did you talk with her about this? what does she know about caring for this baby? how is that going to happen? think of maslow. physical needs of the child come before the psychological needs or the child will die. if the mother is breast feeding there are 3 breast feeding diagnoses to choose from even if the breast feeding is going fine.
there is a sticky thread that has information on writing care plans
and diagnosing. see http://allnurses.com/general-nursing...ns-286986.html
- help with care plans.
it is hard for me to give you much more help because you have not posted any of the mother's assessment data.