POSTPARTUM CLIENT CARE PLAN DEVELOPMENT
Directions: You are the Registered Nurse providing care in Family Centered Care unit of the local hospital. As you provide care to the postpartum client, please place your answers directly below each inquiry. You may use your textbook, other course textbooks, and the internet to complete this activity.
The student will develop a comprehensive plan of care
The student will provide detailed answers to the following questions based on the attached client profile:
What intrapartum history places this client at risk for preeclampsia and/or postpartum hemorrhage?
What collected data helped to identify this risk?
What maternal and newborn assessments are required by the nurse during the postpartum period in general and for this client?
Which laboratory/diagnostic test results for this client are significant for the development of a comprehensive nursing plan of care?
Which nursing actions are a priority for this client? Why?
What comfort measures will be most effective for this client?
What teaching should the nurse provide for this client related to her current medications, pain, and newborn care?
What client care activities would the nurse delegate to unlicensed assistive personnel (UAP) in this situation? Explain your rationale for choosing these tasks to delegate.
What client care activities demonstrate professionalism based on the narrative note provided?
What clinical decisions/actions are required for the nurse to manage the client’s care?
NUR 3450 Postpartum Data Base-
Client:_ Minnie Mouse___ Date of birth __12/22/1993____ Age___26____Allergies: None known___
History: Scheduled C-section for PIH-preeclampsia (BPs 180-200/90-100) during last trimester.
Low blood pressure
4 lb. 9 ounces
Wt. in Kg: _______
ID Band Number:
Breast and Bottle
Complications or concerns during prenatal course, labor/delivery, transition or current time period:
Patient reports a smooth pregnancy with no stress.
Mom’s BP 80/60 during surgery and baby heart rate 90
Concerns: PP hemorrhage, breast feeding, infection, preeclampsia
Religious/Cultural Practices Financial/Legal/Emotional Concerns Support System Cognition Deficits Parent/Sibling Bonding
No religious Practices
Works @ Waffle House,
Has support from father of baby. Excited about new baby. Reported no legal concerns.
3 kids at home excited for new baby. Good relationship with father of child. None Mom and baby are bonding as expected. Mom seems comfortable taking care of newborn.
Teaching Needs-Maternal Care
Return to menses
Signs to report
Signs of UTI
Follow up contact
Signs to Report:
Follow up appointment
Date/Time: Not Received
Teaching Needs-Newborn Care
Back to sleep
Breast milk supply
Shaken Baby Syndrome
Signs to Report
Alteration in skin color
Follow up appointment
_Not received ____________
Admission to L&D Hgb/Hct: __13.2/ 28.9__________Date: on admission
Hgb/Hct 1st PPD: __results not yet unavailable__ Date: _________________
Admission to L&D Vital signs: BP- 181/92, 02-99%, RR-20, HR- 72, Temp- 98.6 F, Pain- 6____
Dose/Route/Frequency Purpose for THIS client Key Data to Monitor (Therapeutic and Non-therapeutic indicators)
IVevery 4 hours (PNR pain)
IVevery 4 hours (PNR pain)
Paroxetine HCL (Paxil)
Nifedipine 30mg – PO- Daily
Lactated Ringers 150ml/hr
Name of Test Normal Values
Admission/ Current 2/13/2020 @ 0700
Significance of Abnormal Value for this client
4.5-11.0 6.8 Within normal values
13.6- 17.2 11.3 Low, blood loss
34.9- 44.5 33.3 Low, low blood volume
PH- 7.35-7.45 (normal)
Concentration 1.000- 1.030
Ph-6.5, concentration- 1.015, small number of ketones present
Other – FBS 103g/dl
NUR 3450 Postpartum Assessment Page __1__ of ___1__
UNCP Nursing Student Documentation
Client: ___Minnie Mouse_______ Allergies __None Known
Date / Time
General survey- When arriving in room, Mom was lying in bed and reported pain @ 6. Mother looked well in appearance, Mother was smiling when communicating with me, no signs of aggravation. Mother worked well with caregivers, baby, and father of child.
LOC- awake and orientated x 3
Delivered baby at 37 weeks 0 Days.
G-4 T-4 P-0 A-0 L-4
Vital Signs: BP: 105/61, P: 85, RR:18, Temp:97.6 F
Emotions- Emotions related from the Mom were very good. She expressed how excited she was about delivering the new baby and was ready to start the journey of being a mother of 4 children. Mother bonded great with the baby. She looked like a pro on taking care of a newborn. While breastfeeding I could see the bond between the mother and baby.
Skin- shinny, smooth, intact.
No signs of swelling, dryness, or edema present.
Heart and Lungs: Heart and lung sounds both clear within normal range.
Heart- No signs or murmur.
Lungs- No signs or distress, no crepitus, no crackling, or wheezing present.
Abdomen and incisions: Abdomen round and smooth, not distended. Mild tenderness due at incision site. Incision site well approximated. Staples intact
Lower abdomen transverse incision with no signs or draining.
Fundus- Located at umbilicus, firm.
Breast Assessment- Enlarged, Mild tenderness was present, darkened and enlarged areola. No signs of hot spots, engorging, or cracks in nipple.
Bowel/ Bladder- flatulence not passed yet. Last bowel movement was at 1200 before coming to hospital. Hyperactive bowel sounds present.
Hemorrhoids and Episiotomy not present. No drains present.
Extremities (Homan’s sign)- Extremities reported no signs of edema, erythema, or warmth. Reporting no signs of thrombophlebitis. Blood return was normal with pulse found. Capillary refill below 3 seconds. Homan’s sign reported negative on right and left leg.
IV site- Insertion on left hand. Lactated Ringers infusing at order rate.
Pain- Pain reported @ 6 most of the day. Only reported increase in pain while lying on side.
Complaints: Only complaint Mom reported was moderate incision site pain, heavy bleeding.
Bonding- Active and present between mother and baby. Skin to skin was completed and bonding occurred. Mother bonded well with baby.
Postpartum Depression assessed with no signs of depression. Mother seems happy and excited. Very friendly.
Nutrition- Diet as tolerated. Only had liquids @ 08:00. Lunch tray was received at 11:00 and patient ate a few chicken nuggets without getting sick.
Lochia- Lochia Rubra present, with half dollar size clots. Saturated peri pad and bed pad in 30 min
Fundus- U+1 and deviated to the right
Vital Signs: BP: 95/54, P: 111, RR:18, Temp:97.6 F
Documentation is to include client assessment, complaints, interventions/evaluation, client/family teaching, bonding, interactions/communication with client, provider or other members of the healthcare team.
Assessment findings include but are not limited to:
Abdominal incision (approximation, drainage, erythema, edema, staples/sutures)
Fundus (location, firmness)
Lochia (amount, type)
Perineum/Episiotomy (approximation, drainage, erythema, edema)
Signs of thrombophlebitis (erythema, edema, warmth, + Homans)
Nutrition (Diet, amount)
Self care activities
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