nursing care plan for OB

Daytonite, BSN, RN · Nov 17, 2009

Deficient Knowledge, specify is the correct diagnosis. There must be a specific topic. How about Deficient Knowledge, baby care?

You know, the first thing I thought of was that this was a very young teenager having a baby. How do you think she's going to handle her own growth milestones? What should she be doing on Erickson's Development Stages? How has having a baby going to change that? In many ways this is also a pediatric care plan--this 13-year old is a pediatric patient.

shortxjieun · Nov 17, 2009

So what kind of goals should I make for her? I know the answers to the questions that you came up with but I don't know how to put all of that into a care plan. I'm just starting nursing school and all this care plan stuff is so confusing...

Daytonite, BSN, RN · Nov 17, 2009

a care plan is about determining a patient's nursing problems. we give those problems names called nursing diagnoses. they are based upon an assessment that you do of the patient in which you collect data about them. you separate out the abnormal data. the abnormal data become the signs and symptoms of these nursing problems. it is evidence that the problems exist. then, you plan out what you are going to do about them. your goals are what you predict you want to happen. your nursing interventions target the signs and symptoms. in other words, nurse, you are treating the signs and symptoms of the nursing problem. sometimes you will be able to do something about what is causing the nursing problem, but mostly you will treat the symptoms in an attempt to, in some way, alter them (improve, stabilize or support their continuation).

for example, with deficient knowledge, baby care. your evidence of this might be the patient telling you she has no idea how to take care of a baby. "what do i dress the baby in? i'm afraid to bathe the baby and that i might somehow hurt him. how often am i suppose to feed him?" one goal might be that by discharge the patient will have demonstrated how to bathe the baby. interventions specific to that goal would include showing the patient a video of how to bathe a baby, giving her a pamphlet on bathing a baby, and having her do a return demonstration of bathing her baby with a nurse present. do you see how all this is dependent on the assessment information that she said she was afraid to bathe the baby and that she might somehow hurt him? do you see how the goal and interventions are related to the symptom? do you see the logic?

now, i don't know exactly what is going on with this 13-year old. only you know that because she was your patient and you know the detailed information. but what i just outlined for you above was done by following the nursing process which is the problem solving and critical thinking tool we have to help us.

step #1 - assess the patient
step #2 - determine the nursing problems based on the abnormal data obtained during assessment
- don't get too hung up on nursing diagnoses. they are labels--names. each has a much longer formal definition that you really need to be aware of and it is more important that you identify the data you have as the correct nursing problem.
  - deficient knowledge (specify) - definition: absence or deficiency of cognitive information related to a specific topic (page 171, nanda international nursing diagnoses: definitions and classifications 2009-2011)
[*]step #3 - plan the care (develop goals and nursing interventions) for each specific nursing problem based on the abnormal data that defines that problem
[*]step #4 - put the plan into action
[*]step #5 - evaluate (or, assess) if you were successful in reaching what you predicted in your goals. if not, revise your nursing interventions.
- ex: goal: by discharge the patient will have demonstrated how to bathe the baby. you will assess if the patient bathed the baby and you might even comment on what she did right and wrong and what areas of the baby bath she needs to work on adjusting your nursing interventions to give more teaching prior to discharge.

you can see examples of care plan construction by the nursing process on this thread:

https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans. i can't be any more specific for you because you haven't provided any specific assessment data about this patient. the foundation of every care plan is that initial assessment data. a care plan will only be as good as the assessment data you put into it.

a thorough nursing assessment consists of:

a health history (review of systems)
performing a physical exam
assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
reviewing the pathophysiology, signs and symptoms and complications of their medical condition
reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking

shortxjieun · Nov 17, 2009

So then what are rationales? My teacher keeps saying to have rationales in our care plan.

With my patient (she's discharged and everything, but we still have to make a care plan for her), her surgery went ok. According to her charts, she had lady partsl lacerations as well as "bil labial" lacerations. She lost > 500 ml of blood (I'm assuming it's because of her lacerations as well). I kept seeing the word "oligio" next to the fact that she was a "teen pregnancy". My clinical teacher was saying that maybe since she was so young, she didn't have enough amniotic fluid or something? I'm not sure, because sometimes she doesn't even make sense and is awful at explaining, hense the reason why I'm online looking for information.

Daytonite, BSN, RN · Nov 17, 2009

so then what are rationales? my teacher keeps saying to have rationales in our care plan.

rationale

- the fundamental reason of something; a statement, or explanation, of reason or principles (page 1207,

webster's new world dictionary of the american language

, college edition, the world publishing company, 1966)

you are providing the reason for why you are ordering that nursing intervention. it should be based on a scientific or nursing principle. for example, we wash our hands with soap, water and use friction. rationale: the soap attracts and holds any bacteria, the friction loosens any bacteria so the soap can grab it and the water washes it all away. this is done to remove as much surface bacteria from the skin as possible.

according to her charts, she had lady partsl lacerations as well as "bil labial" lacerations.

the lady parts lacerates due to labor contractions and the baby's head entering the birth canal and stretching the tissues if a lady partsl birth was attempted before doing the c-section. it can also be from multiple manual examinations by the doctors and nurses.

i kept seeing the word "oligio" next to the fact that she was a "teen pregnancy". my clinical teacher was saying that maybe since she was so young, she didn't have enough amniotic fluid or something?

oligio is a prefix that means few or scanty. did she have oligiohydraminos (less than 300 ml of amniotic fluid at term. principal causes include malformations of fetal urinary tracts, intra-uterine growth retardation, high maternal blood pressure, nicotine poisoning, and prolonged pregnancy.)?

you need to get yourself a good medical dictionary.