L/D Care Plan Help PLEASE

1 Article; 14,604 Posts

Specializes in med/surg, telemetry, IV therapy, mgmt.

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).

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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?

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4. provide nonpharmacologic techniques

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

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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.

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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.

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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?

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#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.

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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.

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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.

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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.

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#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.

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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.

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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.

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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.

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#4 Nursing Diagnosis
Risk for infection r/t multiple lady partsl 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 lady partsl exams and tissue trauma from xx. List it out. Include that episiotomy.

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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.

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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?

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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.

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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.

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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:

Strategies to prevent the problem from happening in the first place
Monitoring for the specific signs and symptoms of this problem
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.

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the_whatsername

1 Article; 3 Posts

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.

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Daytonite, BSN, RN

1 Article; 14,604 Posts

Specializes in med/surg, telemetry, IV therapy, mgmt.

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.

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