Postpartum Care Plan

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    Ok so I am working on my first postpartum care plan and I am having a hard time coming up with some nursing diagnosis and nursing implications that would be needed throughout her pregnancy and after delivery. My patient is a 24 yr old woman with 3 kids already and has had 1 previous abortion and is giving the baby she just had up for adoption. She had a planned c-section delivery and the baby is fine. She has a history of drug use, postpartum depression and was also suicidal during this pregnancy and had a previous attempt. She has also been admitted previously to the psychiatric unit for the suicidal tendencies. She has "boyfriend" but he really is only there for the kids. She has a history of domestic abuse too (from the same man) She seems happy to be giving her baby up for adoption because the adoptive parents will care for the baby the way she cant. I am not even sure what kind of care plan I can come up with all this information. I am leaning towards something dealing with her psychatric issues but I have no idea where to start since I have not even had psych yet and this is supposed to be an OB class. Please help anybody!!
    Last edit by Dramaangel621 on Mar 26, '08

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    There are parenting related ND, impaired parenting, interrupted family processes, compromised family coping, ineffective role performance, that can be related to history of substance abuse, history of being abused, history of mental illness, unplanned or unwanted child. Choose something that fits your case.
    You might want to be careful about "seems happy" because she may have problems with coping, denial, or grieving. Also, the combination of abortion, adoption, and children living with her seems like it would put her at risk for additional mental illness issues.
    I don't want to do your homework for you but I hope this helps a little bit. What nursing diagnosis book are you using? We have to use Cox's Clinical Applications of Nursing Diagnosis. I really don't like it at all so I bought the Ackley book. It is much better.
    Good luck on your care plan. You reminded me that I have a care plan of my own to finish.:typing
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    well, if you were a medical student i might commend you for the nice rundown on the patient's history. but you are a nurse and you are writing a care plan that determines nursing problems, not medical problems. you do that by applying the nursing process. a doctor doesn't even start assigning medical diagnoses to a patient (like postpartum depression) and ordering treatments until he has done a review of systems and assessment using the medical decision making process. nursing diagnosing and ordering nursing interventions is no different. you have to assess the patient first, determine her symptoms, assign nursing diagnoses and then order nursing interventions for the symptoms. every nursing diagnosis has a set of signs and symptoms. nursing interventions are performed on the signs and symptoms that the patient has that you found during your assessment. this is all quite logical.

    please read the information on
    on how to write a care plan. then, if you still have questions i will help you as long as you follow the nursing process. the first thing i need from you is a list of the patient's abnormal data (symptoms).
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    Quote from daytonite
    well, if you were a medical student i might commend you for the nice rundown on the patient's history. but you are a nurse and you are writing a care plan that determines nursing problems, not medical problems. you do that by applying the nursing process. a doctor doesn't even start assigning medical diagnoses to a patient (like postpartum depression) and ordering treatments until he has done a review of systems and assessment using the medical decision making process. nursing diagnosing and ordering nursing interventions is no different. you have to assess the patient first, determine her symptoms, assign nursing diagnoses and then order nursing interventions for the symptoms. every nursing diagnosis has a set of signs and symptoms. nursing interventions are performed on the signs and symptoms that the patient has that you found during your assessment. this is all quite logical.

    please read the information on
    on how to write a care plan. then, if you still have questions i will help you as long as you follow the nursing process. the first thing i need from you is a list of the patient's abnormal data (symptoms).
    thank you for your reply! ok so i read the care plan post and yes it is helpful however i already know most of the content. i am in my second semester of school so i am still having a hard time with the signs and symptoms part...since sometimes the patient has no abnormal findings on examination. her psych issues i found in the chart, i myself saw no signs of these issues but this is what i observed and know of her:

    -her "boyfriend" isnt there for her and appears unimpressed with him
    -holding the baby and sucking her thumb and rocking at the same time (however i dont know if this is of importance)
    -doesnt go to work and receives her support from wic
    -lives by herself with the kids
    -group b strept positivie
    -desires to use contraceptives when she goes home (even after her tubal ligation)
    -c-section went fine with no complications and the incision is healing well with no s/s of infection
    -reports pain around her incision site and grimaced when i felt for the fundus. i asked her what her pain was and she said maybe a 1-2 on scale of 10 at that time but later when i came in she was in no pain
    -complains of gas

    other than that she has no abnormal symptoms. everything on her examination was normal as well as the bubble-he part (breasts,uterus,bowel,bladder,episiotomy,homans sign, emotional)

    i did notice how she wanted to hold the baby when the adoptive parents were in the room and even fed the baby with a bottle and changed his diaper. again...dont know if this is of importance since its not a bad thing since the adoptive parents were fine with it.

    hope this is the information you asked for.
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    So, these are the responses, signs and symptoms you observed in this patient:
    • doesn't go to work and receives her support from WIC
    • lives by herself with the kids
    • Group B Strep positive
    • desires to use contraceptives when she goes home (even after her tubal ligation)
    • incision
    • reports pain around her incision site and grimaced when i felt for the fundus. I asked her what her pain was and she said maybe a 1-2 on scale of 10
    • complains of gas
    • I did notice how she wanted to hold the baby when the adoptive parents were in the room and even fed the baby with a bottle and changed his diaper
    You have to remember that this lady has had surgery and although she is a pospartum patient, she is also a surgical patient. You need to go back to your med/surg textbook and review the care of the general surgical patient because it applies here. If she had general anesthesia, you need to be watching and monitoring for signs and symptoms of complications of general anesthesia:
    • breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism)
    • hypotension (shock, hemorrhage)
    • thrombophlebitis in the lower extremity
    • elevated or depressed temperature
    • any number of problems with the incision/wound (dehiscence, evisceration, infection)
    • fluid and electrolyte imbalances
    • urinary retention
    • constipation
    • surgical pain
    • nausea/vomiting (paralytic ileus)
    If she had an epidural, you need to be monitoring for signs and symptoms of complications of epidural anesthesia:
    • hypotension
    • rash around the epidural injection site
    • nausea and vomiting from the opiates administered
    • pruritis of the face and neck caused by some epidural narcotics
    • respiratory depression up to 24 hours after the epidural
    • cerebrospinal fluid leakage and spinal headache from accidental dural puncture
    • sensory problems in the lower extremities
    In addition, you need to look up information about the cesarean section procedure itself. You need to be aware that the following are risks of this procedure:
    • infection (what's this Group B Strep positive thing about? What was cultured and tested positive?)
    • hemorrhage
    • urinary tract trauma
    • thrombophlebitis
    • paralytic ileus
    • atelectasis
    • anesthesia complications
    When the abdomen is cut into and the bowel is in any way disrupted or touched, peristalsis which is a continual muscular motion in the GI tract, shuts down immediately. Ileus and nausea result. It takes a little time for peristalsis to get restarted and it takes several weeks for it to return to normal. If the patient's bowel was prepped (enemas to cleanse and empty the bowel), then the now quiet and motionless bowel fills with gas because of the normal presence of bacteria in the large intestine. The first symptoms you may see are a distended abdomen and nausea. When peristalsis returns, you assess for bowel sounds, the patient passing gas and finally having the first BM. One of your patient's symptoms is that she has gas. I have no doubt that some of her pain is related to the gas building up in her colon. When, I wonder was her first BM since her surgery?

    Is this lady having any problems with ambulating? You didn't say. Usually with an incision like this women are reticent to get up and move around as they normally would which would warrant a diagnosis of either Impaired Physical Mobility or Activity Intolerance depending on the symptoms they have.

    If she has pain and is getting pain medications and there are comfort measures that can be done for the incisional pain, the Acute Pain applies here.

    To my way of thinking, an incision warrants a diagnosis of Impaired Tissue Integrity, but not everyone agrees with that. I worked on surgical units and this diagnosis was on every surgical patient's care plan.

    I found it interesting that this patient desires to use contraceptives when she goes home even though she has had a tubal ligation. That sounds bizarre to me. Unless there is something I don't know about tubals, she doesn't need contraceptives anymore. It also tells me that she needs some teaching and information about the procedure and the risk of pregnancy. That's a Knowledge Deficit, tubal ligation.

    You noticed that she wanted to hold the baby when the adoptive parents were in the room, fed the baby and changed his diaper. Do you suppose she has some separation or coping issues? I was thinking that she may not be ready to give this baby up. What do you think? It's also interesting that she knows the people she's giving the baby up to--keeps a tie to the baby for her, doesn't it? Decisional Conflict or Risk for Decisional Conflict?Wouldn't be the first time a mother changed her mind and might be having second thoughts.

    Beyond that, unless you want to do some "Risk for" diagnoses for some of the complications listed above. I wouldn't address any of her psych problems. They are not what she is in the hospital for. This is an OB rotation and I'm betting that your instructor is going to be much happier if you address the OB problems which she does have.

    Your nursing interventions address the symptoms that support each of the nursing diagnoses.
    LuvofNursing likes this.
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    Thank you for all of this wonderful information! In my classes we have not yet gotten into the nitty gritty of surgery..I have only taken Adult 1 and surgery is covered in Adult 2. But this is great information for nursing implications. In response to your question, she is not really having problems ambulating. She walked around the unit fine with no pain but just some discomfort with walking. She was eager to get out of bed though to help with the gas. However I will look up which information I would need to have that diagnosis of impaired phsyical mobility or activity intolerance. I too find the contraceptive use bazarre but maybe she wants it to control her menst. cycle and other not so appealing symptoms. And you mentioned separation or coping issues...I personally dont think there were any. She is just like any other mom who still wants to hold the baby and care for him...and with her adoption agency they actually encourage this bonding time. The adoptve parents were fine with everything she wanted to do for the baby. When I was talking with her she seemed very ready to give the baby up and seemed very happy with her choice of adoption. And I think you may have misread some information because she does not know the adoptive parents personally but has come to know them through the adoption agency process. And I am starting to agree with you on not really addressing her psych issues. However, I did notice my clinical instructors writing down all the info for patient so it might seem a little weird if I dont address the psych issues since harm to herself or her children is a priority...and priority diagnosis are what we are supposed to be writing. I think that is one of the tricky parts...picking out the most important diagnosis. It just really bothered me how she tried to commit suicide during her pregnancy so I think I may write about pospartum depression for her. That would incorporate both the OB and psych issues. I cannot seem to find however an approved diagnosis that would incorporate that. Maybe Risk for Post-Trauma syndrome? Risk for Disturbed Thought Process? Or Risk for self-directed violence? Thank you for your help!
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    i am only going by what you posted. of course, you saw and worked with this patient so know better what is going on with her. but, let me say a couple of things about a care olan. you want to address problems that actually exist. don't knock yourself out trying to make problems (i'm referring to the psych issues) that didn't seem to really be an issue during her time in the hospital. past issued and problems are just that--leave them in the past. se's not suicidal now, so it's not a problem now, so it doesn't need to be addressed unless she made comments about suicicidal ideation or told you she had a plan to kill herself. it does sound like this lady might have some behavior issues, but who doesn't? i don't know that they are issues that you really need to address therapeutically. treating psych behavior therapeutically involves going to psych books and looking up the protocols to treat and care planning them. it's like surgical nursing--if you haven't really been exposed to it (because it's very specialized), this isn't the time to start doing it. her behavior from what i can tell isn't outrageous enough to land her in a psych ward. i worked med/surg for years and occasionally we would get a doozy of a psych patient with a medical condition exhibiting some full-blown psych behavior. the nursing interventions for this involved developing a specific plan of treatment that had to be strictly followed by all the staff if it was ever going to work to control the patient's behavior—that's what psych units do and they are very good at it. inevitably, there would be staff nurses who would ignore the care plan and do their own thing and we'd be back to square one with the bad behaviors. i said earlier i would address her surgical issues (she may be playing down the pain she does have or she just may be elated the baby is out) which is not something only psych patients do and ob issues which she does have. i would look at this as an ob patient with a few psych quirks which don't need to be addressed on the care plan. the one creative thing about care planning is that you can interpret the data one way and i can interpret it another. what's most important is how are your instructors going to like your interpretation. so, keep that in mind. this is why i keep going back to the fact that this is an ob rotation, not a psych rotation.

    keep in mind that to diagnose any problem you must have evidence in the form of symptoms. if you are not finding them, and a hunch is not enough, either you are missing something in your assessment and you need to revisit what you are using as an assessment tool or the evidence just isn't there and the problem doesn't exist. there is some good assessment guidelines for all kinds of body systems, including mental health on this thread of allnurses:
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    Thank you so much for your help. I ended up doing Knowledge deficit of self-care needs r/t Post cesarean section delivery and Inadequate understanding of symptoms...didnt even mention the psych issues
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    Boy, am I glad we don't have to do care plans for OB!


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