Care plan for Laboring Woman

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Hey! So I need to come up with a care plan with three priority nursing diagnoses. She is a completely healthy woman who had her baby in like 15 minutes

These are what I'm thinking:

Pain r/t uterine contractions

Knowledge deficit: breathing techniques (?)

Risk for infection (?)

Any help is greatly appreciated!

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There's a HUGE risk here ... think about the C in ABC and think about the Uterus and Pitocin. Think ... the 3rd and 4th stage of labor as well as post partum ... what's THE concern?

Also, how's baby doing in regard to feeding IS she ...keyword... "effectively" breastfeeding? (IF she's even breastfeeding)

What about anesthesia ... did she have an epidural? What did they do right before the epidural (to prevent what?) - what else can happen after an epidural?

Did she have any lacerations or epis?

if so.... how are they healing?

Is she voiding????

You should have done BUBBLE HEE immediately after birth

Breasts?

Uterus? (where was it? was it firm? no? what med do they bolus and what does the nurse do transabd to firm the uterus?)

bladder (is she voiding ... if NOT ... why? what can you do? (warm water etc)

Bowel (is she having BMs ... what is considered normal after birth for not having a BM... how many day is considered OK... What type of births contribute to more constipation? what about opiods?... what about anticipated pain? ... what can YOU do? Does she have hemorrhoids?)

Lochia ... rubra? serosa? alba? how much? spurting? oozing? What does it mean if its dark red? what about spurting?

Episitomy/Laceration ... what degree? pain? rubor? edema?

Homans ... ??? +?? -???

Edama?

Emotions ... how is she bonding?

Assessment..!!!! assessment tells you everything ... lastly... but NOT least what did she express?

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oh and of course....after you give birth and you did ALL that work.

..you'll be TIRED... no? what diagnosis does that go with...

((:

I know these are 4th stage labor directed but I hope they help...

Also, why do you suspect risk infection? Just standard? Was she a PROM? Internal fetal monitoring? Was she on steroids? What makes you think infection? Laceration? Epis? C/S? Diabetic? Not saying infection isn't a Nursing Dx for her... just curious about your R/T and AEB

((:::

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Specializes in ER / Critical Care.

"Had her baby in like 15 mins"

So she had a precipitous labor?

Priority nursing d/x would be

Risk for Hemorrhage RT precipitous labor

And priority always refers to ABC and then work your way up Maslow's. I'd never put a knowledge deficit as priority, especially "breathing techniques" - you said she's delivered the baby... And breathing techniques would be for during labor right?

Im NOT an expert. Just my 2 cents ;)

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

What semester are you? What care plan book do you use?

Care plans are all about the patient.....tell me about yours? Vag birth? C-section? First delivery? Why did she deliver so quickly? Care plans are all about the assessment of the patient....what is the assessment of this patient.

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