nursing care plan

Student Name:

Week:

Dates of Care:

Focus of Care Plan: Labor / Postpartum

(highlight area of focus)

Patient Initials

NC

Sex

F

Age

33

Room

221

Admitting Date

Reason for Admission:

LABOR

Attending physician/Treatment team:

Consults during hospitalization:

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

ER Management: (if applicable)

Allergies:

NO KNOWN

Code Status: FULL

Isolation: (type and reason): NONE

Admission Height:

5’2 (157.5 cm)

Admission Weight:

182 lbs

Pre-pregnancy BMI: 33.28

Arm Band Location (colors & reasons)

Right hand

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

Past Medical History: (pertinent & how managed)

POST DEPRESSION

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

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

Year

Week gestation

Outcome (SAB, IAB, NSVD, C/S)

Sex of Infant

Complications to pregnancy, labor/birth, or postpartum

HEALTH ASSESSMENTS Postpartum or Labor: depending on focus of care plan

Assessments and interventions: (Include all pertinent data)

Vital signs: (2 sets per day)

Postpartum Assessment:

(for PP care plan only)

B:

U:

B:

B:

L:

E:

L:

E:

Respiratory Assessment and Interventions:

S/O:

Interventions:

Cardiovascular Assessments and Interventions:

S/O:

Interventions:

Gastrointestinal Assessment and Interventions:

S/O:

Diet:

Interventions:

Musculoskeletal Assessment and Interventions:

S/O:

Interventions:

Neurosensory Assessments and Interventions:

S/O:

Interventions:

Renal Assessment and Interventions:

S/O:

Intervention:

Skin Assessment and Interventions:

S/O:

Intervention:

Endocrine 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:

Psychosocial Assessment/Interventions: (mental illness, social history, living arrangements, primary care giver, substance abuse, maternal/infant bonding, family dynamics)

Advance Directives/Ethical considerations:

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:

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: Labor care plan: Discuss what is happening physiologically during labor and birth. Postpartum care plan: Describe normal postpartum physiology.)

Pathophysiological Discussion: (If your patient is experiencing a pathophysiological disease process please address 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 general health? 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.)

Safety: (expected and actual needs)

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)

Priority

Nursing Diagnosis

Related to

As Evidence By

Rationale (reason for priority)

1

2

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

Assessment or data collection relative to the nursing diagnosis

(provide subjective and objective assessments)

Patient Outcome (objective, expected or desired outcomes or evaluation parameters)

INCLUDE 2 COUTCOMES

(S-M-A-R-T)

Interventions/Implementations and Rationale

(specific nursing actions- MUST include a rationale with each intervention)

(INCLUDE at LEAST 3 INTERVENTIONS AND RATIONALES)

Evaluation

(include whether outcome was met, partially met or unmet)

If the outcome is “unmet” what is your plan to meet outcome in the future?

Assessment or data collection relative to the nursing diagnosis

(provide subjective and objective assessments)

Patient Outcome (objective, expected or desired outcomes or evaluation parameters)

INCLUDE 2 COUTCOMES

(S-M-A-R-T)

Interventions/Implementations and Rationale

(specific nursing actions- MUST include a rationale with each intervention)

(INCLUDE at LEAST 3 INTERVENTIONS AND RATIONALES)

Evaluation

(include whether outcome was met, partially met or unmet)

If the outcome is “unmet” what is your plan to meet outcome in the future?