Postpartum care plan

  1. 0
    Pt 24yo female 1 day postpartum. Baby is in NICU due to other complications but only the mother was my pt. I need five diagnoses total and I only have four. If there is any input on the four I have already that would be appreciated also. Due in 24hrs.
    A. Ineffective breastfeeding r/t situational crisis AEB pt verbalization of not being able to breastfeed while her baby is in the NICU.
    NOC: Pt will use breast pump effectively by the end of shift.
    NIC:
    1) Educate pt on the use of the pump. This will ensure correct use.
    2) Assist pt with use until the pt feels confident to use independently. Assisting the pt will ensure confidence when performing independently.
    3) Observe pt use breast pump independently. Observing will confirm correct use.
    Eval: Goal met; Pt demonstrated correct use of the breast pump independently as 1130. Cont. POC

    B. Acute pain r/t episiotomy AEB pt states, “It hurts when I sit or walk. I would rate my pain at a 6 or 7. I really need something to make the pain better.”
    NOC: Within 4 hours of interventions pt will experience a decrease in pain level by reporting a pain score of 2 or less.
    NIC:
    1) Administer analgesic medication as ordered as needed to promote comfort.
    2) Explain discomforts and reassure the pt that they are time limited to assist in coping with pain,
    3) Administer stool softener to prevent straining with first bowel movement
    Eval: Goal met; Pt stated pain level at a 2 one hour after interventions. Cont POC

    C. Impaired tissue integrity r/t episiotomy AEB 3rd degree laceration in the perineal area
    NOC: The pt will remain free of infection through out shift, without any signs and symptoms of infections, and exhibit evidence of progressive healing as demonstrated by clean, dry, absent edema, and intact episiotomy site.
    NIC:
    1) Monitor episiotomy sire for redness, edema, warmth or discharge to identify infection
    2) Instruct pt on use of sitz bath to promote healing, hygiene and comfort.
    3) Encourage frequent perineal care and peripad changes to prevent infection
    4) Instruct pt on positioning to relieve pressure on perineal area
    Eval: Goal met; Pt showed signs of progressive healing as demonstrated by clean, dry, absent edema and intact episiotomy site.

    D. Risk for ineffective coping r/t mood alteration and pain
    NOC: The pt will cope with mood lacerations, by verbalization of positive statements about newborn and participation in new born care
    NIC:
    1) Provide a supportive, nurturing environment and encourage the mother to vent her feelings and frustrations to relieve anxiety
    2) Encourage pt to travel up to the NICU to spend time with the newborn
    3) Offer praise and reinforcement of positive mother-infant interactions to enhance self-confidence in care
    Eval: Goal met; “Even though it hurts to walk I feel that it is worth it to go and see the baby.”
    Cont POC
  2. 11 Comments so far...

  3. 1
    That all looks good to me. I might add some more interventions, I know my teachers wanted a lot more than what you listed.
    Do you have to write one more physical or psychosocial?
    Which way are you leaning? What do you see as a problem or potential issue? If you can give something to work with, it's easier to help you phrase it.
    Allie0188 likes this.
  4. 0
    She needed to ambulate. But the only thing keeping her from that was pain. I was not sure if impaired physical mobility was appropriate. Also we only have to have three interventions minimum.
  5. 2
    With a 3rd degree tear she's at risk for constipation, you might add that. There's also risk for impaired parenting if the baby is in the NICU.
    Summer Days and Allie0188 like this.
  6. 1
    I think you came close to this, but along with your skin integrity issues, you have risk for infection. That might be another way to go. I agree with the role problems (parenting). That's where my mind went right away.
    Allie0188 likes this.
  7. 0
    What Would your interventions be for impaired parenting with the baby in the NICU
  8. 0
    Well, would kind of depend on whether the NICU is in the same hospital. Again, anything to offer? I'm glad to help, but don't want to do your homework for you!
  9. 0
    Think....you just had a baby but it has to be in the ICU for babies....how will that affect how you care and bond with your baby? How does it change what you can do for your baby? What is "wrong" with the newborn that may impact the ongoing care of this infant when they get home?

    How can you as the nurse help the Mom?
  10. 0
    Risk for impaired parenting r/t baby in the NICU AEB pt states " I just don't feel like a mom yet."
    NOC: pt will verbalize one positive statement about parenting by end of shift.
    NIC: 1) Explain to pt that babies time in the NICU is limited to encourage pts outlook
    2) Encourage pt to go and see baby as much as physically able to establish bonding
    3) ...................
  11. 0
    How is she COPING with the baby in the NICU? It's not just that it interrupts the parenting process. How is she handling it emotionally, especially if she can't breastfeed?


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