Nursing care plan for.....

you must follow the nursing process in writing any care plan, the steps of which are:

1. assessment
   
2. determine problems (nursing diagnosis)
   
3. planning (developing goals and interventions)
   
4. implementation
   
5. evaluation

so, the very first thing you need to do is go through the assessment data that you collected from the patient's medical record, from the physical assessment you did and from talking with the patient. what did you find out that wasn't normal? those abnormal things become this patient's symptoms (nanda calls them defining characteristics) and they become the basis for any nursing diagnoses that you will end up using for this patient. you also want to look at the underlying reason for the patient's hypertension. since the hypertension is chronic, did her doctor indicate in the chart any underlying reason for the hypertension? there might have been some clues about this in the patient's medical history. is this patient obese? is there a pre-existing heart condition? does she have any peripheral edema? that is important information to know that will have an impact on her treatment. since this is a postpartum patient, you also have to look at the data you collected about the birth process. were there any problems during labor and delivery? was there an episiotomy? or, did the patient tear? many times there is internal trauma due to the baby coming through the birth canal that no one can see as the baby pushes through this small space. swelling of the internal tissues occurs and can result in urinary retention and microtears of the tissue that can later lead to hemorrhage and infection. did hemorrhoids form? or, did this patient have a c-section? with a c-section there is an incision to be concerned about. is the mother breastfeeding? if so, how is she doing with that? what drugs and treatment have the doctor ordered for this patient? why? are any of these drugs likely to affect the baby if the mother is breastfeeding? is the mother concerned about this? is this a first time mother? does she need any teaching with regard to baby care or home care for herself? all this information should have been gathered during your assessment and provides you with clues to help you determine what this patient's nursing problems, goals and interventions are going to be. it is not enough information for any of us to help you when all you provide us with is a medical diagnosis. a medical diagnosis tells us nothing of this patient's nursing needs and you and we are nurses, not doctors. no decisions about care on a care plan can be made until you have examined the patient and investigated all the facts of her case.

for more information about this see the posts on these threads:

• https://allnurses.com/forums/f205/desperately-need-help-careplans-170689.html - desperately need help with careplans (in nursing student assistance forum)
  
• https://allnurses.com/forums/f50/careplans-help-please-r-t-aeb-121128-7.html - careplans help please! (with the r\t and aeb) (in general nursing student discussion forum)

if you are still having difficulty getting started with this care plan, please post a list of this patient's abnormal assessment data (symptoms) as well as any information you have about the underlying reason of the hypertension and how the labor and delivery went and i will help show you how to proceed from there.

Your only symptom is an oral temperature of 101.4 postpartum. You also say her temperature is rising. You should provide evidence of that. If you have other elevated temperature readings, I would also list them with your AEB items. "Body temperature elevated above normal range" is not an official NANDA nursing diagnosis. If you are permitted to word your own nursing diagnoses, this is fine. If you are to use NANDA diagnoses, you need to change this and I would correct the grammar to: Hyperthermia R/T medications and anesthesia AEB postpartum oral temperatures of 101.4, xxx, and xxx.

In your outcome and interventions you bring up shivering. Is this a symptom that this patient had? If so, it needs to be included in your AEB items. Otherwise, my feeling is that rather than have interventions for it which indicate that it is an actual problem the patient has, you should have interventions to monitor for it.

what would be some good nursing outcomes for a postpartum woman unable to void on her own???? i need some suggestions plz!! i was going to say "patient will void unassisted 6-8 hours after delivery, but i wasn't there 6-8 hours after i was there 12 hours after delivery. my ndx is : impaired urinary elimination related to urethral trauma as manifested by inability to void. we ended up having to cath her at the end of clinicals.

you haven't provided any of the proper information for me to be able to help you.

please read the information on how to write a care plan on this thread:

• https://allnurses.com/forums/f50/help-care-plans-286986.html - assistance - help with care plans (in the general nursing discussion forum)