Help With Nursing Care Plan Please! =)

[Stephanie89]

I have to write a nursing care plan for my parent-child class after each clinical rotation and we had some bad snow here so i had to work on both a mother and a baby and will have 2 logs do and im just trying to get them both done now. The Mother is 2 days postpartum and the baby is obviously 2 days old. Here is what ive got:

My instructor told me that really the only thing i could work with with my mom was that she had low fluid intakes because she was very healthy so im thinking that my diagnosis will be: fluid volume deficit related to excessive edema of the feet and ankles and decreased fluid intake.( i was there for 5 hours and she had only taken in 530ML) I cant really think of any measurable goals but so far i have patient will express increases comfort in feet and ankles by end of shift? Outcome i have patient will demonstrate adequate fluid balance as evidenced by balanced intake and ouput and a decrease in edema of the feet in ankles by the end of each shift. Intervention i have encourage fluid intake of 210ML or 7OZ of fluid every 1-2 hours, assist patient with fluids if necessary, teach the patient about the needs for adequate intake of fluid after pregnancy and for breast feeding. and to elevate both legs with pillows. Im not really sure what to do about evaluation because of my clinical rotation i dont really get to see her leave the hospital (that is why i used end of shift) so if i use end of shift theoretically i would have to say that outcome criteria was not achieved as evience by edema and low fluid intake because that is how she was when left her?

My baby was also healthy and the only thing i really have to work with is that she was jittery so i am going to make my diagnosis risk for nutrition imbalance: less than body requirements. I really need help on some goals. I was thinking that outcome would be decrease in jitter evidenced by calm state? intervention would be increase in visitations to mother for feedings? again for my evaluation i would have to put outcome criteria was not achieved as evidenced by jitter states and frequent crying? I need some help with the childs plan for sure!

also for my rationale i came up with everything on my own so im just using my nursing texts as ref.

thanks for helping it means so much!!!:redbeathe

[Daytonite, BSN, RN]

mother

so, all you did for the entire 5 hours was attend to the mother's fluid status? when a baby gets pushed out of someone's uterus and down the birth canal, tissues get damaged. when tissues are damaged, the body responds by releasing histamines and beginning the inflammatory response (redness, heat, swelling and pain). is she in any pain? internal swelling can cause urinary retention. did she have an episiotomy? if so, that is a surgical incision that needs care and monitoring. did she have any kind of anesthesia/epidural? the complications of anesthesia that need to be monitored for are 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, and sensory problems in the lower extremities. what's going on with her fundus and lochia? is she breastfeeding? there are 3 diagnoses for breastfeeding including one for a mother who is breastfeeding and having no problems.

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. that's ineffective thermoregulation r/t immature compensation for changes in environmental temperature. [see https://allnurses.com/forums/f50/newborn-nursing-diagnosis-346647.html for information on thermoregulation of temperature in newborns and nursing interventions.] 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 ([color=#3366ff]risk for infection). if the baby 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 ([color=#3366ff]imbalanced nutrition: less than body requirements).

[Stephanie89]

thank you