Postpartum Care Plan Help!

Use the information you have. The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. They are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly. I use Ackley: Nursing Diagnosis Handbook, 9th Edition and Gulanick: Nursing Care Plans, 7th Edition

Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE

1. Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, 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)
   

Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

What I would suggest you do is to work the nursing process from step #1. Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you. What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list. This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

The patient I had gave birth to a healthy baby, but it was taken for an ECG because the physician heard a heart murmur that was more pronounced than it would be normally in a newborn. This patient had a child last year that died soon after birth from Trisomy 18. I want to have a nursing diagnosis for this. I was thinking Anxiety r/t previous child passed away from Trisomy 18....but I don't think the r/t part is right

Did you assess for anxiety? What about coping? Caregiver role strain? Did the patient say anything. Care plans are all about the assessment of the patient NOT your observations. What did the patient say? what did she do? What did her SO/DH do?

This is why a good care plan book is imperative. I use Ackley: Nursing Diagnosis Handbook, 9th Edition and Gulanick: Nursing Care Plans, 7th Edition

Caregiver role strain:

Difficulty in performing family caregiver role

Defining Characteristics

Caregiving Activities

Apprehension about care receiver's care if caregiver unable to provide care; apprehension about the future regarding care receiver's health; apprehension about the future regarding caregiver's ability to provide care; apprehension about possible institutionalization of care receiver; difficulty completing required tasks; difficulty performing required tasks; dysfunctional change in caregiving activities; preoccupation with care routine

Parental role Conflict:

Parent's experience of role confusion and conflict in response to crisis

Defining Characteristics

Anxiety; demonstrated disruption in caretaking routines; expresses concern about perceived loss of control over decisions relating to his or her child; fear; parent(s) express(es) concern(s) about changes in parental role; parent(s) express(es) concern(s) about family (e.g., functioning, communication, health); parent(s) express(es) feeling(s) of inadequacy to provide for child's needs (e.g., physical, emotional); reluctant to participate in usual caretaking activities, verbalizes feelings of frustration, verbalizes feelings of guilt

Fear: Response to perceived threat that is consciously recognized as a danger

Defining Characteristics

Report of alarm; apprehension; being scared; increased tension; decreased self-assurance; dread; excitement; jitteriness; panic; terror

Cognitive

Diminished productivity; learning ability; problem-solving ability; identifies object of fear; stimulus believed to be a threat

Behaviors

Attack or avoidance behaviors; impulsiveness; increased alertness; narrowed focus on the source of fear

Physiological

Anorexia; diarrhea; dry mouth; dyspnea; fatigue; increased perspiration, pulse, respiratory rate, systolic blood pressure; muscle tightness; nausea; pallor; pupil dilation; vomiting

You are welcome.......they are right the in your care plan/nursing diagnoses book.