Nursing Care Plan 23-year old Post partal

2bRnKim · Apr 9, 2008

Hi! To anyone reading this, I really need help. I'm a nursing student in level 3 training(SEA curriculum) and a real amateur in making a nursing care plan. I know how to make the basic NCP's for easy cases like Ineffective Airway clearance..etc but Maternal Care is not really my thing so I need help in identifying a proper diagnosis and Interventions for this particular theoretical case for practice:
Ms. X, 23 y/o is a primigrav post partum 3 days. In an interview by the health worker, she states that she doesn't know how to take care of her baby and says: "I'm afraid that I won't be able to raise my child well" she also fears that her baby may become malnourished because she can't perform breast feeding properly. She also states that she lacks the proper knowledge in taking care of the infant and fears that she may only harm the child when giving care.
I think it's a simple problem but I am having a problem in identifying a diagnosis and the proper interventions for it.
Hope someone can help me as soon as possible, and thanks for all the ideas I may learn from this.

Hi, Keep in mind that you are to use NANDA approved diagnosis for your client. Here are some ideas:

Knowledge deficient R/T breastfeeding

Risk for ineffective family coping

Anxiety R/T birth of baby

Anxiety R/T being a first time mother

I dont' know how many you need, but she seem's pretty easy to do a careplan on. Good luck.

Kim

Check out the links for making careplans for specfic instructions.

Daytonite, BSN, RN · Apr 10, 2008

how were these other care plans you made different, other than the fact that this patient has nursing problems involving a different body system? a care plan is the written documentation of the problem solving process. if you follow the steps of the nursing process which is the problem solving process nurses use, you'll get your care plan out of it and it won't matter what disease or procedure your patient has. as a nursing student care plans are done to help you learn about diseases and procedures. theoretical cases are one way instructors have to do that as well as to get students to stimulate their critical thinking skills. following the steps of the nursing process is how you start to do that. the steps of the nursing process and what occurs in each of them with respect to writing a care plan are:

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/procedures to learn about the signs and symptoms and pathophysiology)
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)
planning (write measurable goals/outcomes and nursing interventions)
implementation (initiate the care plan)
evaluation (determine if goals/outcomes have been met)

you cannot even begin to identify a proper diagnosis or develop nursing interventions for this hypothetical patient until you have completed step #1 of the nursing process which is assessment. both nursing diagnoses and nursing interventions are based upon the symptoms (in nanda language they are called defining characteristics) the patient has. these symptoms can only be determined through collection and analysis of your assessment activities.

think about this for a minute. have you ever heard of a doctor who diagnosed any disease without first doing a physical exam and ordering and reviewing test data? have you ever doubted a reputable car mechanic who determined that your car needed new brake pads without looking at and examining the ones already on your car first? why would a nurse jump to any conclusions about the nursing diagnoses on any patient without using the same proficiency?

another thing is that the nursing diagnoses are not based upon medical diseases. they are all pretty generic, so to speak, and designed to be used for med/surg patients, pediatric patients, psych patients, ob patients, and any other kind of patients. the major division of the nursing diagnoses is between actual problems and potential problems.

with a theoretical case you are generally given specific symptoms. i caught them right away when i read the scenario, but keep in mind that i've been a nurse a long time. how can you learn to recognize the symptoms? look at the activities to do for step #1 of the nursing process (assessment)

collect data from medical record (in his case, the scenario you were given)
do a physical assessment of the patient (in this case, read your ob textbook on what the discharge teaching needs are for the first time mother with regard to baby care and breastfeeding. if you can't find much in your textbook, there is gobs of information on the internet. there are also a whole bunch of ob weblinks posted on this thread: https://allnurses.com/forums/f50/maternal-child-heath-who-learning-semester-200689.html)
the remainder probably doesn't apply

symptoms, for nursing problems are not quite the same as symptoms for medical diseases. they will include them, but will also be such things as

problems performing adls
statements by the patient that indicate they are in mental discomfort of some type with a situation
behavior that seems a little (or a lot) odd that the patient exhibits in response to a situation or to the way they feel
the things they say that indicate they are not thinking appropriately or plan to act the way a normal person would think or act
the things they don't do to keep up their health

it is interesting to read through the defining characteristics (symptoms) listed with the individual nursing diagnoses in the nanda taxonomy to see what some of these symptoms are. which brings up a very important point: every nursing diagnosis has a list of symptoms. you patient must have, at the least, one of them or more in order to assign that nursing diagnosis to the patient. this is another reason for assessing the patient. you are never going to find those symptoms until you have thoroughly assessed the patient. for students it is important to look up the signs and symptoms of medical diseases because you are not familiar with seeing them in the clinical area. signs and symptoms will be staring you in the face and you will miss them because you just didn't know they were there. when you sit down to write the care plan you can read about them in your textbooks and the light bulb in your brain clicks on and you make the correction to your care plan paperwork. this is how we all learned this information. assessment is something that takes many, many years to master.

after assessment you develop a list of the patients symptoms. from that list you will look for defining characteristics that match nursing diagnoses that apply to your patient, treat those symptoms by developing nuring interventions for them and determine goal/outcomes that predict the results of your nursing interventions. the care plan, in fact, is founded on the abnormal data (symptoms) you ascertain from your assessment data.

m

s. x, 23 y/o is a primigrav post partum 3 days. in an interview by the health worker, she states that she doesn't know how to take care of her baby and says: "i'm

afraid

that i won't be able to raise my child well" she also fears that her baby may become malnourished because she can't perform breast feeding properly. she also states that she

lacks the proper knowledge in taking care of the infant

and

fears

that she may only harm the child when giving care.

i've highlighted the abnormal data that was given to you in the scenario--done part of step #1 of the nursing process for you, these items are the evidence (symptoms) that will support the nursing diagnoses you will use. it seems you need to do some investigation of newborn care and breastfeeding in order to develop your nursing interventions and goals/outcomes. there are nursing diagnoses for these problems.

good luck.

aga_aquino29 · Apr 10, 2008

Thanks, to tell the truth, I'm pretty new at making NCP's and have a real difficulty in getting a good grasp of the nursing process. Though I have a good idea of how ADPIE works my critical thinking skills need some improvement. During my class this morning, my instructor revised the case she gave us to practice on, and to me it was far more "easier" to make a plan than the old theoretical case.

Anyway, thanks a lot for the tips and I was able to make my NCP. And I would really appreciate it, if you could comment on this Nursing Care Plan I made on the revised case.

Ms. Sarah Perez, is a 23 y/o 3-day post partal mother to her first child; she is not married but currently living in with her boyfriend only in a medium sized two-storey home. She is a librarian at a university library but is currently on leave and the income is currently earned only by her boyfriend who is a teacher. The local community nurse arrives at her house for the mother’s first check up. The health worker observes the client to be restles. Ms. Perez states “I have been lacking some sleep ever since the baby but it’s not a problem and I can still manage it” She is also observed to have hearing problems based by her delayed reactions to the health worker’s questions. When asked of how she is managing her baby Sarah was hesitant to speak but then replies “I love my baby very much, but to tell the truth I’m afraid that I won’t be able to raise my child well. I have this feeling that I might suddenly hurt my child while he is in my arms.” She continues “I almost dropped him(baby) while trying to breast feed”The nurse observes that the patient is hesitant to hold her baby and while breast feeding appears to have difficulty in positioning her baby right. She states “I’m not sure if my baby would grow up healthy because I don’t know how to breast feed.”

Assessment:

Subjective: “I have been lacking sleep ever since the baby but it’s not a problem…”

“I love my baby very much, but… I’m afraid that I won’t be able to raise my child well…”

“…I have this feeling that I might suddenly drop my child while… in my arms.”

“I’m not sure if my baby would grow up healthy…”

“…I don’t know how to breast feed.”

Client states that she almost dropped her child while breast feeding.

Objective: 23 years old

Occupation: Librarian

3 day post partum to first child

Client observed to appear restless and,

hesitant to talk about taking care of baby,

hesitant to hold baby

and has difficulty in breast feeding baby.

Problems accdg to priority:

1) Ineffective parenting (of neonante) as observed from and verbalized by client

Diagnostic Statement/s:

Impaired Parenting related to Lack of knowledge about child health maintenance, parenting skills and child development.

Planning:

Goal: Demonstrate appropriate Parenting skills in child health and development.

Objectives: After 2-3 days of health teachings and demonstrations the client will:

verbalize basic understanding of parenting and basic child rearing

enumerate at least 5 ways of ensuring proper child growth and development

perform procedures of maintaining a healthy environment for a growing child

perform proper breast feeding techniques with out difficulty

explain the reasons and importance of actions performed.

Interventions:

1) Assess parenting skill level, taking into acount the patients intellectual, emotional and physical strengths and weaknesses through discussions with parent. [Parents with impairments may need more assistance or further education]

2) Evaluate physical limitations of parent by peforming a physical assessment on the client. [sense impairments may effect the parents capacity to care for the child]

3) Assess parent-child attachment behaviors through observation and interview and proper health teachings as needed. [bond between parent and child affects greatly the quality of care the parent gives to the child]

4) Provide health teachings on parenting skills, child rearing and breast feeding; and encourage client to attend skills courses. [in order to assist client in learning and developing the needed skills for proper parenting]

5) Emphasize general parenting function rather than fathering/mothering function. [by virtue of gender each parent have unique capacities in parenting, but the nurturing role can be performed by both parents]

6) Assist parents in time management and conservation of energy. [Enables the parents to cope effectively with difficulties as they arise.]

7) Identify with client all available community resources. [To assist with the client’s needs to provide support.]

Evaluation Criteria:

Objectives will be fully met if:

Mother respond well to interventions, showing decreased signs of anxiety when nurturing baby and is able to properly perform the demonstrated parenting skills with the knowledge of proper child rearing.

-end of plan-

aga_aquino29 · Apr 10, 2008

Thanks for your advice and I was able to use them on this revised version of the case my instructor gave me this morning. But I hope you can give your comments on the plan I made and if you tell me how I can improve on making Nursing Plans. Much Appreciated!

-Aga

here is the plan I made, love to hear your comments.

Ms. Sarah Perez, is a 23 y/o 3-day post partal mother to her first child; she is not married but currently living in with her boyfriend only in a medium sized two-storey home. She is a librarian at a university library but is currently on leave and the income is currently earned only by her boyfriend who is a teacher. The local community nurse arrives at her house for the mother’s first check up. The health worker observes the client to be restles. Ms. Perez states “I have been lacking some sleep ever since the baby but it’s not a problem and I can still manage it” She is also observed to have hearing problems based by her delayed reactions to the health worker’s questions. When asked of how she is managing her baby Sarah was hesitant to speak but then replies “I love my baby very much, but to tell the truth I’m afraid that I won’t be able to raise my child well. I have this feeling that I might suddenly hurt my child while he is in my arms.” She continues “I almost dropped him(baby) while trying to breast feed”The nurse observes that the patient is hesitant to hold her baby and while breast feeding appears to have difficulty in positioning her baby right. She states “I’m not sure if my baby would grow up healthy because I don’t know how to breast feed.”