In the documents

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

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NRG5000 Theoretical Foundations of Nursing

Dr. Lisa Capps, Faculty

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NUR4025 Maternal Newborn Care Plan Assignment Rubric

Student Name: _______________________________ (Select): Postpartum Labor Newborn

Description

Totals

Patient Information and Health Assessments

· Complete Patient Demographics

· Reproductive History

Information Related to Current Pregnancy

Information Related to Prior Pregnancies

· Newborn Information (if delivered)

· Current Medication

· Lab Work/Diagnostic Data

____/ 5

Nursing 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

____/ 2

Complete a Nursing Process Table for the primary nursing diagnosis

Assessment:

· Appropriate for chosen diagnosis

· Includes objective & subjective historical support diagnosing data

·

____/ 3

Patient Outcomes:

· Include at least 2 outcomes for the diagnosis

· Specific to the patient diagnosis

· Contains the following 4 criteria:

measurable, attainable, realistic, and timed

· All criteria present for patient’s expected outcome

____/2

(Outcome 1)

____/ 2

(Outcome 2)

I
ntervention/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 (Interventions and Rationales for Outcome 1)

____/ 3

(Interventions and Rationales for Outcome 2)

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

Nursing and the Care of Childbearing Families

Student Name: Gladys Mireku Date of Care: 10/2/2022

Focus of Care Plan: (highlight one Labor/Birth Postpartum Newborn


Identifying information
: Complete information section for MOTHER on Labor Care Plan


Complete information sections for MOTHER and NEWBORN on Postpartum and Newborn Care Plan

MOTHER Initials: M.K Gravida 1 Para 0 (4-digit Parity) EDC: 9/27/2022 Gestational age: 41 weeks

Amniotic fluid Clear (clear or meconium in fluid) Prenatal Group B Strep: Positive
Did mom receive antibiotics in labor: Yes

Abnormal prenatal test results:
Not Known QBL: Not yet Blood Type: A positive Type of anesthesia used during labor and/or birth (if applicable): Not yet Current Medications: Pitocin, Dilaudid ,Misoprostol

Episiotomy or laceration (describe by type and/or degree):Not yet

NEWBORN Initials’ Birth date: Time of birth: not yet Sex: Female Gestational age: not yet Birth weight Not known lbs./oz. grams

Age (in hours): Not yet APGAR scores at birth: Not yet (one minute), Not yet (5 minutes) Method of feeding: Breast feeding

Blood type: Not yet known Coombs: Not yet known TCB or TBili: Not known Glucose: Not known


Additional Information:
Complete information below for Labor, Postpartum, and Newborn Care Plans

Type of birth: (circle) vaginal delivery Cesarean-section Vaginal Birth After Cesarean (VBAC) not born yet

Is there history of any high-risk situations or complications during previous pregnancy, labor/birth, or postpartum period? YES : NO; None

If yes, please list:

Is there history of any complications during current pregnancy, labor, birth, postpartum, or newborn? YES: NO:

If yes, please list:


Nursing Diagnosis: (include all 3 components): Diagnosis

Pain
R/T__________ASB_________________________

Assessment or data collection relative to the nursing diagnosis

(provide subjective and objective assessments)

(This is your assessment of your patient)

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)