L/D Care Plan Help PLEASE

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I need help with my nursing care plan for a labor/delivery patient.

What does a labor/delivery care plan include?

L/D Care Plan Help PLEASE

I am a level one RN student on my first OB clinical rotations and care plans are still very new to me. I must turn in a concept map with supporting data for each of my diagnoses and an intervention sheet with at least 6 interventions and patient responses to each. Minus the patient responses, here is what I have so far:

#1 Nursing Diagnosis

Acute Pain r/t uterine contractions and stretching of cervix and birth canal

Supporting Data

External monitoring of contractions, Patient states "I am hurting," noticeable facial grimace, muscle tension, increased RR, Client rates pain as 9/10, diaphoresis

Goal

Client will report that pain management regimen relieves pain to satisfactory level

Outcome

Client will maintain

Interventions

  1. Assess pain level every hour and prn
  2. Administer Stadol IV every 4 hrs and prn
  3. Assist with epidural
  4. Provide nonpharmacologic techniques
  5. Encourage client to try different positions
  6. Teach simple breathing and relaxation techniques
  7. Limit visitors as she desires
  8. Keep informed about the progress of labor and Baby's condition
  9. Prevent pain when possible during procedures

#2 Nursing Diagnosis

Fatigue r/t childbirth

Supporting Data

Unknown (help)

Goal

Patient will verbalize increased energy and improved well-being

Outcome

Patient will verbalize environment is suitable for satisfactory rest during my shift

Interventions

  1. Assess level of fatigue prn
  2. Allow client to express what best helps her relax
  3. Limit visitors as she requests
  4. Prepare the environment to promote rest
  5. Administer pain medication to relieve pain and promote rest
  6. Limit the number of times she is interrupted Try to administer medication, check VS, or or other actions in one room visit
  7. Teach methods to help relax

#3 Nursing Diagnosis

Anxiety r/t fear of unknown and situational crisis

Supporting Data

Facial tension, increased perspiration, increased pulse (?) ----- (This doesn't sound right)

Goal

Patient will have vital signs that reflect baseline and will verbalize decreased anxiety

Outcome

Patient will have a relaxed facial expression and body posture between contractions

Interventions

  1. Determine the couple's plans for birth and work with them as much as possible
  2. Explain all activities, procedures and issues that involve the client
  3. Stay with client as much as possible during labor
  4. ?
  5. ?

#4 Nursing Diagnosis

Risk for Infection r/t multiple vaginal exams and tissue trauma

Supporting Data

Unknown (help)

Goal

Patient will remain free from infection

Outcome

Patient will free from signs of infection as evidenced by normal VS during my shift

Interventions

  1. Assess and report signs of infection such as Swelling, discharge, increased body temp and warmth
  2. Follow Standard Precautions
  3. Use sterile technique when inserting Foley
  4. Use appropriate hand hygiene
  5. Teach patient proper perineum care
  6. Teach patient the symptoms of infection and when to report to physician
  7. Teach patient proper episiotomy care
  8. Monitor VS

I am a 27 year old mother of three beautiful girls who is engaged to married this July, all while trying to survive nursing school. I am in my second semester of the RN program at the local community college.

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6 Comment(s)

Daytonite, BSN, RN

Specializes in med/surg, telemetry, IV therapy, mgmt. Has 40 years experience.

I spent a great deal of time going through your care plan. For the most part it is pretty well organized, but I did make a lot of suggestions for you.

A care plan is a listing of the patient's nursing problems and strategies to do something for them. Everything flows from your supporting data which come from your initial assessment of the patient.

Two things:

(1) Is she breastfeeding? There is a diagnosis for that whether the breastfeeding is going OK or if there are problems.

(2) You made mention of an episiotomy. That is a wound that requires nursing attention. I gave you a diagnosis for it below and I think that should be included in the care plan. It is also a source of potential infection.

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#1 Nursing Diagnosis

Acute Pain r/t uterine contractions and stretching of cervix and birth canal

Supporting Data

External monitoring of contractions, Patient states "I am hurting," noticeable facial grimace, muscle tension, increased RR, Client rates pain as 9/10, diaphoresis

What about the episiotomy?

Your goals and outcomes need to be reversed. Outcomes refer to the overall outcome of the diagnosis and usually go back to the related factors. Goals have to do with how your nursing interventions impact on the symptoms (your supporting data).

Quote

Interventions:

1. Assess pain level every hour and prn
2. Administer stadol IV every 4 hrs and prn
3. assist with epidural

How is assisting with her epidural going to decrease her pain?

Quote

4. provide nonpharmacologic techniques

Like what? This is a very vague intervention. I'll list some for you below.

Quote

5. encourage client to try different positions
6. teach simple breathing and relaxation techniques
7. limit visitors as she desires

Limiting visitors doesn't belong here.

Quote

8. Keep informed about the progress of labor and baby's condition

How is this going to decrease her pain? This sounds more like it needs to be an intervention with your diagnosis of anxiety.

Quote

9. Prevent pain when possible during procedures

Pain during procedures is not among your supporting data (symptoms), so why would you have a nursing intervention for it? Makes no sense.

One of your interventions should at least be mentioning the pain scale of 0 to 10 that is being used to assess the pain since you mention it as an outcome and have included it as supporting data.

What are you doing for the diaphoresis?

Quote

#2 Nursing Diagnosis

Fatigue r/t childbirth

Supporting data

Unknown (help)

How can you even diagnose that the patient is fatigued without her having any symptoms of it? Your supporting data would be the symptoms of the fatigue. Look at the defining characteristics of fatigue.

Quote

Goal:

Patient will verbalize increased energy and improved well-being.

Outcome:

Patient will verbalize environment is suitable for satisfactory rest during my shift.

Your goals and outcome need to be reversed.

Quote

Interventions:

1. Assess level of fatigue prn
2. Allow client to express what best helps her relax
3. Limit visitors as she requests
4. Prepare the environment to promote rest
5. Administer pain medication to relieve pain and promote rest
This intervention belongs with acute pain.
Quote

6. Limit the number of times she is interrupted try to administer medication, check vs, or or other actions in one room visit

Do room visits cause her fatigue or anxiety? Hmm. If they cause anxiety this should be part of your supporting data for anxiety and belongs with that diagnosis.

Quote

#3 Nursing Diagnosis

Anxiety r/t fear of unknown and situational crisis

Supporting Data:

Facial tension, increased perspiration, increased pulse (?) ----- (This doesn't sound right)

Yet they are. read up on anxiety. They are physiologic responses. All are listed as defining characteristics of anxiety in a nursing diagnosis reference.

Quote

Goal:

Patient will have vital signs that reflect baseline and will verbalize decreased anxiety

Outcome:

Patient will have a relaxed facial expression and body posture between contractions

Your outcome should reflect the related factor. Goals should be predictions of what will happen when your interventions for the symptoms (facial tension, increased perspiration, increased pulse) are performed as you planned.

Quote

Interventions:

1. Determine the couple's plans for birth and work with them as much as possible

This makes no sense being here. you have no supporting data that their plans for birth have or are the cause of any anxiety.

Quote

2. Explain all activities, procedures and issues that involve the client
3. Stay with client as much as possible during labor

NEED MORE INTERVENTIONS!

The problem with your interventions is that they do not target the symptoms of the anxiety (your supporting data, or symptoms). Just like doctors, we also treat the patient's symptoms. In this case, you are saying her symptoms of the anxiety are facial tension, increased perspiration, increased pulse. your interventions need to be what you are going to do about them.

The definition of anxiety, the nursing diagnosis, is vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger. It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with the threat (page 242, NANDA International Nursing Diagnoses: definitions and classifications 2009-2011).

What will you do to allay those feelings of fear and dread? Better still...Did they verbalize them at all? If so, they are supporting data (symptoms) that you need to include above.

Quote

#4 Nursing Diagnosis

Risk for infection r/t multiple vaginal exams and tissue trauma

Supporting Data

Unknown (help)

There is no supporting data because this is not an actual problem that exists yet. It is a potential problem. There are only risks that it could happen. The risks are that she has had xx vaginal exams and tissue trauma from xx. List it out. Include that episiotomy.

Quote

Goal:

Patient will remain free from infection

Outcome:

Patient will free from signs of infection as evidenced by normal vs during my shift

Your goal and outcome need to be reversed.

Quote

Interventions:

1. Assess and report signs of infection such as swelling, discharge, increased body temp and warmth
2. Follow standard precautions

What are standard precautions and why are they important to the prevention of infection?

Quote

3. Use sterile technique when inserting foley
4. Use appropriate hand hygiene

What is "appropriate" hand hygiene? you need to be more scientific. spell it out exactly.

Quote

5. Teach patient proper perineum care
6. Teach patient the symptoms of infection and when to report to physician
7. Teach patient proper episiotomy care

This patient has an episiotomy? That's another nursing problem and diagnosis impaired tissue integrity.

Quote

8. monitor vs

Again, outcome should be that the patient will be free of infection. Goals will reflect predictions of what will happen when your interventions for the potential symptoms do not occur or your interventions are performed as you planned. With "risk for" diagnoses nursing interventions are restricted to the following:

  1. Strategies to prevent the problem from happening in the first place
  2. Monitoring for the specific signs and symptoms of this problem
  3. Reporting any symptoms that do occur to the doctor or other concerned professional

Interventions for Pain:

  • Assess and document patient's level and intensity of pain using the 0 to 10 rating scale with 0 being no pain and 10 being the worst possible pain
  • Assess and document where the pain is located and what, if anything, makes it worse or better
  • Observe and document any of the following physical responses: frequent changing of body position, moaning, sighing, grimacing, crying, restlessness, dyspnea, tachycardia, diaphoresis, pallor
  • Give pain medication as ordered
  • Provide emotional support by spending time talking to the patient and reassuring them that measures are being taken to relieve their pain
  • Reposition the patient
  • Give a back massage
  • Use short, simple relaxation exercises to distract the patient's attention
  • Dim the lights in the room and keep noise down
  • Play soft, soothing music
  • have the patient perform slow deep breathing and concentrate on feeling weightless with each breath
  • Reassess and evaluate the patient's response to each method employed. ask the patient which techniques work better for them.
  • Monitor for side effects of narcotic therapy: respiratory depression, constipation, nausea/vomiting
  • Teach the patient about prescriptions they will be going home with including the dosage, how they should be taken and any side effects

Symptoms

Also called defining characteristics by NANDA, these are the abnormal data items that are discovered during the patient assessment. They can also be the same signs and symptoms of the medical disease the patient has, the patient's responses to their disease, and problems accomplishing their ADLS. They are evidence that prove the existence of the nursing problem. If you are unsure that a symptom belongs with a nursing problem, refer to a nursing diagnosis reference. these symptoms will be the focus of your nursing interventions and goals.

Thank You so much! I am so new to this and I know I am probably making this more difficult than it should be. I just have been feeling very overwhelmed and the stress of it all is getting to me. You've helped me understand better HOW to work a care plan and I thank you for breaking it down like you did.

Daytonite, BSN, RN

Specializes in med/surg, telemetry, IV therapy, mgmt. Has 40 years experience.

The first care plans you do will seem difficult and go slow. It takes time to adjust and learn this nursing process and diagnosis business. There are 206 nursing diagnoses. Most nurses only know a handful of them off the top of their heads. I am still surprised that classes in nursing diagnosis aren't formally taught in all nursing schools. We all take some kind of classes in pathophysiology which is pretty much learning the medical diagnoses, but many nursing schools fail when it comes to teaching students the nursing diagnoses and the process of how to diagnose. The process (nursing process) isn't much different from what doctors do except the information that goes into our diagnosing includes not only some medical information, but other stuff that doctors aren't particularly interested in that is of more concern to us nurses. Remember back to when you first learned to ride a bike and even farther when you were learning to tie shoelaces. You didn't do either perfectly the first time. . .or the second time. . .or the third time. It takes practice and lots of it. Just keep at it.

Part of why I post here is to help students get a better understanding of this seemingly complicated process. I am always looking for and thinking about ways to explain or make this whole care plan process easier for people just learning it. If you have any confusion about the process, please ask. I'll dig into my bag of tricks and see if there is something there that can help you. Chances are I have already posted it on a thread somewhere on this forum already anyway, but I will repeat this stuff when questions are asked.

2nd year midwifery.. Can u help me find all nursing diagnosis r/t to labor and delivery NANDA list? Thank you

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

Guting said:
2nd year midwifery.. Can u help me find all nursing diagnosis r/t to labor and delivery NANDA list? Thank you

Where are you going to school? are you in the US?

The NANDA list nanda list but that does not contain the "taxotomy" or definitions for each diagnosis....do you have a care plan book?

I start nursing school in August. These seem really interesting but complicated!