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Confused about this??

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by sherriberry1 sherriberry1 (New Member) New Member

sherriberry1 works as a 2009- 2011 ADN NURSING STUDENT.

2,838 Visitors; 94 Posts

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Hi everyone!!! I am confused about writing this care plan....I am in my OB clinical rotation. I have been in post partum for two clinicals and today I was in L & D....so I need to come up with interventions and diagnosis that involve that area but I am wanting to do it like the past two weeks for the post partum care plans...its weird I know but I just seem to be stuck in that mode. My client today was 20 yrs old second pregnancy, asthma, grade II/ VI heart mumur,substance abuse,pit. induction.........I am wanting to do something on the substance abuse issue but I do not think that would fit in L & D??? Maybe more of the discharge teaching maybe.... I just FEEL that needs to be address somehow. A few I have come up with is acute pain r/t pitocin induced labor process, Risk for maternal/fetal injury r/t obstetrical complications, and Potential for post partum hemorrrhage r/t cervical or vaginal laceration or hypotonic uterus.....I just need to know if I am heading in the right direction.

Thank you in advance!!!:heartbeat

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5 Likes; 3 Articles; 99,343 Visitors; 14,602 Posts

an l&d care plan is no different from a med/surg care plan. you still go through the same process for determining the nursing problems. you are just dealing with a different set of data that involves the gynecological system and the birthing process.

the first thing you need to do is assess that patient. you also need to know the birthing process and its pathophysiology just as you do for any other medical disease or condition. the only information you've provided in this post is all about the patient's medical conditions. we are nurses. we deal with how the patient responds and reacts to what is happening to them. so, when you assess the patient you think about what you know about the birthing process and what it does to the patient's body. think about what happens to the birth canal as a baby comes through it. does damage to the tissues occur? is that where some of the pain comes from? what happens when tissues are damaged? the inflammatory response sets in: redness, heat, swelling and pain. just because it is internal and you can't see it doesn't mean that it isn't happening. this is not different from a med/surg patient that comes in with some kind of physical trauma except we call it part of the normal birthing process. what else happens to the woman's body when that baby comes through the birth canal? how does it affect the bladder and the anus? is she breastfeeding? there are 3 nursing diagnoses that involve breastfeeding whether things or going well or not. if you want to address the patient's substance abuse problem you care plan for it just as you would for a med/surg patient, but is it affecting the labor and delivery process? i get that you "feel" it needs addressing, but care planning and the nursing process is scientific and you have to address the evidence in front of you. if there is no evidence of a problem now, then leave it alone. you cannot begin to write nursing interventions until you have gone through your assessment data and found the abnormal data that is going to be the evidence of the nursing diagnoses you end up with. you will do nursing interventions for the symptoms of each nursing diagnosis.

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acute pain r/t pitocin induced labor process

you cannot use a medical treatment as the cause of her pain here. her pain is due to the contractions she is having or the afterbirth pain. did she have an episiotomy. that can be a cause of pain as well.

risk for maternal/fetal injury r/t obstetrical complications

you need to be able to actually list what procedures she had that are putting her at risk for injury. also, i would not include fetal injury with the diagnosis because this care plan is about the mother and not the fetus.

potential for post partum hemorrrhage r/t cervical or vaginal laceration or hypotonic uterus

this is not an official nanda diagnosis. hemorrhage is a medical decision so you really can't use it in a nursing diagnosis. what you can use is
risk for bleeding
.

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sherriberry1 works as a 2009- 2011 ADN NURSING STUDENT.

2,838 Visitors; 94 Posts

DAYTONITE

Thank you so much for your reply and I respect you very much....:)

My class is getting into care plan writing and it is QUITE CONFUSING....I do not have any experience in Med -Surg yet that will come after our spring break in a few weeks. The very first ones I did I recieved a U on so my instructor gave my a chance to rewrite them. She told me that the second ones were much better than the first and I was on the right track but I just had to organize and elaborate more. I guess it it like anything else..... Pratice makes perfect :D

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949 Visitors; 10 Posts

If u want to do something for the substance abuse issue, how about complications related to the babys prenatal exposure to drugs? Depending on what drugs the pt was on- failure to thrive?

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5 Likes; 3 Articles; 99,343 Visitors; 14,602 Posts

If u want to do something for the substance abuse issue, how about complications related to the babys prenatal exposure to drugs? Depending on what drugs the pt was on- failure to thrive?

The problem is that the care plan is about the mother. You can't mix up mother and baby problems on one care plan.

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saah58 works as a Student.

753 Visitors; 15 Posts

Daytonite

I just started the RN program. Foundations is killing me, every question is based off of critical thinking. I can not seem to wrap my head around these types of questions. Are there practice questions I can do that are online for me to get familiar with? What can I do to increase my grade in class??? I saw one of your other comments to a post and I would really appreciate any help you have to offer.

Thanks in advance.

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sailornurse has 39 years experience and works as a FNP;Urgent Care; Asthma-Allergy-Immunology.

1 Like; 16,897 Visitors; 1,231 Posts

FYI Daytonite is in Nurse Heaven having left us about 5 years ago. She was wonderful helping students. The thread you responded to is 6 years old.

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saah58 works as a Student.

753 Visitors; 15 Posts

Well her posts are really helpful, but I need practice on critical thinking questions....

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JustBeachyNurse has 10 years experience and works as a Nurse.

10 Likes; 1 Follower; 98,898 Visitors; 13,943 Posts

Well her posts are really helpful, but I need practice on critical thinking questions....

Get an nclex prep book. Saunders used to be organized by concept (fundamentals, medicine, pharmacology, etc)

If Delegation is an issue get Planning Delegation and Assignment by Linda LaCharity

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