Neonatal and maternal concept map / care plan

[JA27]

First time here. Hopefully you can point me in the right direction. I am a second semester RN student. Our assignment is to create a concept map for a newborn (seems like a care plan) and a concept map for the mom (depending on csect or lady partsl). I need help with all of it -- the nursing diagnosis, interventions, goals. There's a great care plan creator at elsevierhealth.com but it is geared towards adults and only a little that I can use. Anyone know of a great resource for the little ones and mom? Thanks so much for any input!

[APBT mom, LPN, RN]

Do you have a care plan book? They'll usually have all the info that you need and you can tweak them a little for a infant or pp mother.

[Daytonite, BSN, RN]

hija27, and welcome to allnurses!

Are these real patients you took care of, or just made up patients?

A care plan is nothing more than your documentation of the nursing process which is the problem solving method that we use. There are several ways a care plan can be documented. A care map, or concept map, is one way. A case study is done as an essay. There is also a critical pathway and a chart style. There is information on how to do nursing concept maps along with several examples of care maps you can look at on this sticky thread on this forum:

All care planning and problem solving is based upon the assessment of the patient and the abnormal data, or signs and symptoms, that you discover during your assessment. The nursing diagnoses, goals and nursing interventions are all based upon those symptoms. You must follow the steps of the nursing process in writing any care plan and in the sequence that they occur:

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)

You assessment is, by far, the most important step of the process because everything else in the care plan depends upon what you discover during the assessment. So, if these are not real patients, then you merely need to go through the normal c-section or lady partsl birth process and list out the normal complications that occur. These will then serve as your symptoms for the care plan you are developing.

With a c-section you are basically dealing with a surgical patient. You need to consider the complications of either general or epidural anesthesia. If the patient went through labor there will also be some trauma to the internal tissues as a result of the stretching of the tissues from the labor. All of that needs to be addressed as either actual or potential problems on a care plan for this patient.

With a lady partsl delivery you have to consider the trauma to the internal tissues of the mother as the baby has made it's way through the lady partsl canal. You need to know what happens when tissues are damaged by trauma and how they respond. There are specific complications that can occur even when there has been a normal lady partsl delivery. These form the basis for the problems on a care plan for this patient.

With any mother, there is always a lot of teaching that needs to be done regarding their own aftercare as well as baby care. All of that can be incorporated into a care plan.

The baby also needs to be assessed. Mucus in the airway and other airway problems are the primary thing to observe for. Also, babies are not able to regulate their body temperature, so they are at risk for hypothermia. If they have a low bilirubin level and need to be placed under the bili lights they are at risk for injury from accidental burns from the lights. They are also at risk from injury due to forceps used during delivery or skin breakdown. Some babies do not get the hang of sucking and so breastfeeding or feeding from a bottle becomes a problem that needs to be addressed. And, in the case that feeding is going ok there is a nursing diagnosis for that: effective breastfeeding.

Here are threads on writing care plans that you might want to look at when you have time. Lots of good information in them:

Here are some very good ob links you should bookmark and use to help you:

• https://emedicine.medscape.com/emergency_medicine#obgyn - listing of emedicines emergency topics - scroll down to obstetrics to find the emergency ob conditions that go wrong and click on the individual problems
• Interpretation of the Electronic Fetal Heart Rate During Labor