Care P

NRG5000 Theoretical Foundations of Nursing

Dr. Lisa Capps, Faculty

Guidelines for Nursing Process: Maternal Nursing Patient Care Plan

Nursing Diagnosis:

Nursing diagnosis consists of the diagnostic label, “related to” and the “as evidence by” components.

A “Risk for…” diagnosis does not have “as evidence by”.

Diagnostic label: Is selected from the NANDA International Diagnosis.

“related to” the condition or etiology of the problem the patient is experiencing.

“as evidenced by” assessment data that supports diagnosis

Assessment as evident by (AEB), or data collection relative to the nursing diagnosis

Outcome (objective, expected or desired outcomes or evaluation parameters

Interventions/

Implementations/

SHOULD HAVE RATIONALE FOR EACH INTERVENTION

Evaluation

(Each OUTCOME needs an evaluation statement)

Assessment supports the nursing diagnosis above. The assessment should reflect the “defining characteristics” that are expected to be present for that diagnosis to be appropriately utilized.

Types of data: subjective & objective

Sources of data

Nursing health history

Physical examination

Diagnostic data

The OB care plan will focus on short term outcomes.

“What do you/your patient want to achieve today? …at next assessment?”

Should be acceptable by the patient and the nurse, realistic, specific and measurable

Stated realistic behavioral terms that can be observed, measured and relevant to the identified nursing diagnosis.

Intervention –

The planned nursing actions that are likely to achieve the desired outcomes

Interventions should reflect on going assessment and activities that will assist in achieving the goal/outcomes.

Interventions should reflect independent nursing practice as well as collaborative practice.

Interventions should reflect the needs of this specific patient not a generic listing of possible interventions.

Interventions should include specifics like schedules, food choices, frequency, etc….

Rationales- reasoning behind your choosing the intervention; scientific explanation and/or underlying reason for which the intervention was chosen for your patient

Focuses on change and compares the changes with the outcomes

Essentially this is a reassessment of the patient and the responses as to the interventions implemented.

Compare actual patient behaviors with expected behaviors.

Consider the effectiveness of the nursing intervention, time elements.

Give reasons why or why not each outcome has been met.

If the outcome is “unmet” what is your plan to meet outcome in the future or does the outcome need to be revised?

NRG5000 Theoretical

F

oundations of Nursing

Dr. Lisa Capps, Faculty

1

5

NUR4545: Maternal Nursing Care Plan Assignment

Student Name:	Week:	Dates of Care:
Focus of Care Plan: Labor / Postpartum / NB (highlight area of focus)

Patient Initials

M.Z.

Sex

F

Age

2

9 y/o

Room

1176

Admitting Date

11/18/20

Reason for Admission:

Delivery

Attending physician/Treatment team:

George L. Stan

Consults during hospitalization:

Ehimiaghe, Eseohi MD

Present Diagnosis: (Why patient is currently in the hospital)

ER Management: (if applicable)

Allergies:

NKDA

Code Status:

Full (No ACP forms)

Isolation: (type and reason)

Contact Precaution

Droplet Precaution

Admission Height:

Admission Weight:

Pre-pregnancy BMI:

Arm Band Location (colors & reasons)

Communication needs: (verbal, nonverbal, barriers, languages)

N/A

Past Medical History: (pertinent & how managed)

Hypothyroidism

Significant Events during this hospitalization: (include date, event and outcome)

Tests/Treatments/Interventions impacting clinical day’s care: (include current orders)

Pregnancy history: (for ALL care plans)

Gravida: 1 Para: T (Term): 1 P (Preterm): 0 A (Abortions): 0 L (Living): 1

Year	Week gestation	Outcome (SAB, IAB, NSVD, C/S)	Sex of Infant	Complications to pregnancy, labor/birth, or postpartum

History of current pregnancy: (for ALL care plans)

LMP: 2/2/2020 EDD: 11/18/2020

Gestation age: 41weeks

3

days

Total number of prenatal visits: 4

Complications or risk factors during current pregnancy: GBS

Prenatal education: (if yes, describe type; for instance: class, book, online…

History of current labor and birth: (for ALL) care plans)

Onset of labor (date, time):

Rupture of membranes (date, time): 11/18/2020 Color of fluid:

Delivery date and time: Weeks gestation: 41weeks 3days

Delivery type: SVD

Newborn weight: 7lbs 8oz

Total length of labor:

Fetal presentation at delivery:

Episiotomy and/or laceration (describe by type and/or degree):

Estimated blood loss: 255cc

Anesthesia type (epidural/local/IV/none): Epidural

Labor complications: None

Newborn History: (for Postpartum and Newborn care plans)

Gestation age by dates: 41week 3days

Gestation age by exam: 41weeks 3days

Birth weight: 7lbs 8oz

Length: 50.5cm

Head circumference: 36cm

Chest circumference:

Blood type (if done):

Delivery date & time: 11/7/2020

Delivery type: SVD

1-minute APGAR score: 8

5-minute APGAR score: 9

Method of Feeding: Breast Feeding

HEALTH ASSESSMENTS Postpartum or Labor: depending on focus of care plan Assessments and interventions: (Include all pertinent data)
Vital signs: (2 sets per day) Time T P R B/P Pulse Ox Pain Score Time T P R B/P Pulse Ox Pain Score	Gastrointestinal Assessment and Interventions: S/O: Diet: Interventions:
Respiratory Assessment and Interventions: S/O: Interventions:	Neurosensory Assessments and Interventions: S/O: Interventions:
Cardiovascular Assessments and Interventions: S/O: Interventions:	Musculoskeletal Assessment and Interventions: S/O: Interventions:
Renal Assessment and Interventions: S/O: Intervention:	Skin Assessment and Interventions: S/O: Intervention:
Pain Assessment and Interventions: S/O: Pain score: Assessments/Interventions: (scale used, location, duration, intensity, character, exacerbation, relief, interventions)	Vascular Access: (IV site) Assessment and Interventions: S/O Assessments/Interventions: (include type of fluid & access, location, dressing, date inserted, tubing change)
Endocrine Assessment and Interventions: S/O: Intervention:	Post-operative /procedural: Assessment and Interventions: S/O: Intervention:
Safety: S/O: Interventions:	Advance Directives/Ethical considerations:
Maternal Diagnostic Data Results and date Normal Lab Values Significance to your patient Blood type (A, B, AB, O) RH Factor (“+” or “-“) Antibody screen (if Rh negative) Prenatal H & H Postpartum H & H Rubella status GBBS WBC RBC Platelets HIV Hepatitis B GTT Newborn Diagnostic Data Blood type (A, B, AB, O) RH Factor (“+” or “-“) Coombs test Blood glucose Cord blood bilirubin TCB/Serum bilirubin (please note whether value is TCB or serum and hour of life test completed Glucose
Psychosocial Assessment/Interventions: (mental illness, social history, living arrangements, primary care giver, substance abuse, maternal/infant bonding, family dynamics)
Cultural/Spiritual Assessment and Interventions: (religious preference, adaptations & modifications, end of life decisions)
Growth & Development Assessment and Interventions: (physical, psychosocial, cognitive, moral, spiritual using various theorist) What stage of development evident with patient:

Postpartum Assessment: (for PP care plan only) B: U: B: B: L: E: L: E:

Current Plan of Care: (summarize the anticipated plan of care for mother or baby, depending on the focus of the care plan)

Discharge Plan: (Briefly state when, with whom, and to where the patient anticipates being discharged)

Teaching needs: (Identify the teaching needs for this mother and/or family; bullet points OK)

PLEASE NOTE: The physiology/pathophysiology discussion should be in the student’s own words. Cite the source of the information using APA format. Normal Physiology Discussion: (All care plans must have a brief discussion of the normal physiology related to their specific patient. (Examples: Discuss what is happening physiologically during labor and birth. Describe normal postpartum physiology. Discuss newborn physiology immediately following and in the first hours after birth.) Pathophysiological Discussion: (If your patient is experiencing a pathophysiological disease process please address at the cellular level (in your own words). Explain why this patient is encountering this particular health deficit. What is the relationship of this current health alteration to the patient’s other medical conditions? Describe the current disease process the patient is encountering: etiology, epidemiology, pathophysical mechanism, manifestations and treatment (medical and surgical). Also note the complications that may occur with these treatments and the patient’s overall prognosis. (Include appropriate references and use APA format.)

2

List of nursing diagnoses (NANDA format). Place diagnoses in priority order and provide rationale for priority setting.

2

Priority	Nursing Diagnosis	Related to	As Evidence By	Rationale (reason for priority)
1
3

Medications	Classification	Dose, Route, Frequency	Purpose/Mechanism of Action (Why is THIS patient on this medication?)	Significant Side Effects/ Adverse Reactions (related to THIS patient)	Nursing Implications
Acetaminophen (Tylenol)
Benzocaine 20% spray 1 Spray
Biscacodyl (DULCOLAX) Suppository
Diphenhydramine tab (BENADRYL)
Colace

Nursing Diagnosis: (include all 3 components)

	Assessment or data collection relative to the nursing diagnosis (provide subjective and objective assessments)		Patient Outcome (objective, expected or desired outcomes or evaluation parameters) (S-M-A-R-T)		Interventions/Implementations and Rationale (specific nursing actions- MUST include a rationale with each intervention)		Evaluation (include whether outcome was met or unmet) If the outcome is “unmet” what is your plan to meet outcome in the future?

Nursing Diagnosis: (include all 3 components)

Assessment or data collection relative to the nursing diagnosis
(provide subjective and objective assessments)

Patient Outcome (objective, expected or desired outcomes or evaluation parameters)
(S-M-A-R-T)

Interventions/Implementations and Rationale
(specific nursing actions- MUST include a rationale with each intervention)

Evaluation
(include whether outcome was met or unmet)
If the outcome is “unmet” what is your plan to meet outcome in the future?

NRG5000 Theoretical Foundations of Nursing

Dr. Lisa Capps, Faculty

1

Maternal Nursing Care Plan Assignment Rubric

Student Name: __________________________________________________

Description

Points Received/

Total Points Possible

Comments

Diagnosis #1

Diagnosis #2

Totals

Patient Information and Health Assessments
· Complete patient demographics, health assessments, and interventions

____/ 3

Pharmacology:
· Complete& accurate description of current meds, including purpose for this patient, side effects, and all other data listed in chart

____/ 3

Pathophysiology:
· Includes “signs and symptoms”
· Includes APA references cited

____/ 3

Nursing Diagnosis (Included 2 diagnosis):
· Reflects the primary diagnosis
· Appropriate for patient scenario as well as priority level
· In acceptable NANDA format
· Includes all parts stem, R/T, AEB
· Only 1 ‘Risk For’ diagnosis can be used

____/ 3

Provided 2 nursing diagnoses: 2 points per diagnosis

____/ 4

Assessment:
· Appropriate for chosen diagnosis
· Includes objective & subjective historical support diagnosing data

____/3

+ ____/3

= ____/ 6

Patient Outcomes:
· Include at least 2 outcomes for each diagnosis
· Specific to the patient diagnosis
· Contains the following 4 criteria:
measurable, attainable, realistic, and timed
· All criteria present for patient’s expected outcome

____/3

+ ____/3

= ____/ 6

Intervention/Implementation:
· Include at least 3 nursing interventions for each patient outcome
· Includes interventions/ nursing actions directly relating to pt. outcomes
· Specific in action, frequency and contain rationale
· # of interventions is appropriate to help pt./ family meet their outcomes

____/3

+ ____/3

= ____/ 6

Evaluation:
· Must have an evaluation statement written for each patient outcome
· Includes all data that is listed as criteria in outcomes
· Outcomes are determined to be met, partially met, or not met
· If outcome was not met/ partially met, plan of care is revised/ continued & new evaluation date/time is set

____/3

+ ____/3

= ____/ 6

Total Points: ____/ 40