Care Plan Help!

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Hi everyone! I am in my second clinical experience with my peds/ob clinical. I am having trouble coming up with nursing diagnosis for a first time mother who gave birth at 40.4 weeks. She had a healthy baby boy. I need to come up with a nursing diagnosis for attachment, emotional assessment, educational needs, and postpartum risk factors. I am not sure where to start because she done an excellent job with the breastfeeding and the other education requirements. Thank you!

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

You will never go wrong if you follow the nursing process in writing a care plan. You will only falter in what you lack in knowledge to contribute to the assignment or a lack of where to find the knowledge. The steps of the nursing process as it pertains to care planning are:

  1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
  2. determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
  3. planning (write measurable goals/outcomes and nursing interventions)
  4. implementation (initiate the care plan)
  5. evaluation (determine if goals/outcomes have been met)

Everything for this care plan rests upon the assessment that you did. your assessment activities include the following, some of which you already did at the hospital:

  • a physical assessment of the patient
  • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
  • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
  • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.

Always keep in mind that in doing assessment it is important that you know what a normal response is supposed to be.....the purpose of assessment when you are care planning is to look for abnormal responses because these are clues (evidence) that a nursing problem exists. Assessment includes looking up pathophysiology, signs and symptoms and medical treatment for any medical conditions that exist. You are only going to know this by knowing what is normal about the process of labor and birth. much of that information should be in your ob textbook.

Think....close your eyes for a second and try to visualize a front seat view of a 7-pound baby coming through the birth canal. What's happening to those tissues in that mother's body! while birthing may be a "normal" process (right!) all that stretching and tearing of those tissues is not! those are injured tissues. What do you know about the pathophysiology of cell and tissue injury? it sets off the inflammatory response. you are not necessarily going to see the resulting signs and symptoms (redness, heat, swelling, pain) because these tissues are deep in the body, but i guarantee they are occurring..... think about the effect this has on the mother's body and surrounding organ structures.

From our Daytonite (rip)

there are also complications of birthing and any procedures that were done to assist the birth that need to be taken into consideration:

  • infection due to
    • episiotomy
    • multiple lady partsl examinations
    • labor lasting more than 24 hours
    • prolonged time between rupture of membranes and birth
    • manual extraction of the placenta by the doctor
    • diabetes
    • urinary catheterization

    [*]pain of the lady partsl tissues

    [*]bladder distension or inability to urinate

    [*]infection in the uterus

    [*]hemorrhoids occur during the pushing of labor

    [*]hemorrhage risk

    • if this is mom's 6th or more child
    • prolonged labor
    • retained placenta
    • induced labor
    • if tocolytics were given to stop contractions
    • c-section
    • forceps delivery or vacuum extraction of the baby

here are possible nursing problems (which you would need to turn into nursing diagnoses) that you would determine from abnormal assessment information that you had gathered:

  1. women experience afterpains, perineal trauma, their breasts are often engorged with milk and many have hemorrhoids. was there an order for tylenol or motrin?
  2. if you had gone through 10 or 20 hours of labor how would you be feeling after it was all over? tired, perhaps? drained of energy? need some sleep and rest? hungry? thirsty? need some fluid replacement?
  3. is the mother breastfeeding? there are 3 nursing diagnoses for breastfeeding: effective, ineffective and interrupted breastfeeding the baby can also have this diagnosis with its own nursing interventions.
  4. when the baby comes through the lady partsl canal the bladder suffers a temporary loss of sensation for a period of time and there is also a decreased muscle tone to the bladder. this can result in urinating problems.
  5. some mothers experience orthostatic hypotension as a result of vertigo after childbirth sometimes because of blood loss or dehydration. they could fall and injure themselves.
  6. many new mothers need teaching regarding care of their episiotomies, prevention of complications and their own health maintenance. some need complete information about baby care, the baby's needs and their normal behaviors.

for the baby:

Think about what you know about the assessment findings of a normal newborn compared to an adult. what's different? for one thing newborns can't regulate their body temperature which is why we don't leave them exposed to the room atmosphere for very long with just a diaper covering them......ineffective thermoregulation r/t immature compensation for changes in environmental temperature.

Some newborns just have a few difficulties with excessive secretions in the respiratory track (the big hint here is that the nurses will keep a bulb syringe nearby the baby) so ineffective airway clearance can be used. they also have a stump from the umbilical cord hanging off their future belly button. do you? are they treating this cord stump? if it's inflamed or there are umbilical cord problems there is risk for infection, so you can use risk for infection r/t break in skin integrity at umbilical cord site .

if the baby is a male and has been circumcised that is another reason for a risk of infection. is this baby breastfeeding? if so, use effective breastfeeding. and, some babies just don't start feeding well at first by breast or bottle--it happens. these kids are imbalanced nutrition: less than body requirements r/t poor infant feeding behaviors.

if the baby is under the bililight for hyperbilirubinemia the nursing diagnosis to use is risk for injury r/t phototherapy

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