Maternal Nursing Care Plan-Assignment Solution

(highlight area of focus)

DF

F

27

LDR2

03/05/2021

Term pregnancy admission for delivery

APN

No

Labor / delivery

N/A

No known allergy

No isolation

Pre-pregnancy BMI:25.25kg/m2

White band, Newborn Id band

Verbal; English is her second language. Speaks English fluently, No language barriers

Thyroid disease

Hypothyroidism complicating pregnancy

N/A

Assessments and interventions: (Include all pertinent data)

(for PP care plan only)

B:

U:

B:

N/ A

B:

L:

E:

L:

E:

S/O:

She is breathing at a regular rate

Interventions:

S/O:

Heart rate was within normal range, skin was pink and there was no edema.

Interventions: Encourage ambulation

S/O:

Diet: She is taking regular diet.

Interventions: Regular diet as she tolerates.

S/O: Moves all extremities with no pain. No numbness

Interventions: Encourage ambulation

S/O: No numbness or Tingling

Interventions: None

S/O: She was able to void

Intervention: she needs to void every 2 to 3 hours

S/O: Access for sores, skin color and breakdown, no pressure ulcer, skin was intact.

Intervention: Continue to monitor skin and maintain good patient care.

S/O: Patient has hypothyroidism

Intervention: Monitor input and out

S/O: Contraction

Pain score: 9

Assessments/Interventions:

(scale used, location, duration, intensity, character, exacerbation, relief, interventions)

No pain medication was given as it was toward delivery of the baby.

S/O

No redness or swelling.

Assessments/Interventions: (include type of fluid & access, location, dressing, date inserted, tubing change)

Continue to monitor for redness and swelling.

S/O: Patient has Hypothyroidism and no gestational diabetes

Intervention:

S/O: Patient has second degree laceration

Intervention:

Patient living with her partner with another child

No smoking, No substance abuse.

None

No cultural practice currently

According to the Erikson stage of development this patient is in the intimacy vs. isolation period. This is because this stage pertains with person between the age 20 and 40 and it involve young adult struggles to form close relationships and to gain capacity for intimate love.

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.)

The patient at this point is going through recovery and involution. This is the process by which the uterus is transformed from pregnant to non- pregnant state during the postpartum period. first 1-2hours check vital signs every 15minutes, check the bleeding, check the fundus, Palpate the abdomen to check where the uterus is located if it is firm. She can get up after 2 hours to empty her bladder to prevent bleeding. During this period, the uterus can be found between the umbilicus and the symphysis pubis, but after 6-12 hours after delivery the uterus is found on the umbilicus. The uterus reduces each day by 1cm below the umbilicus by help of contraction (Ricci 2017). By the 14 days the uterus descends to the pelvic cavity, and you cannot palpate. After one week the uterus is decreased to 50 percent in size and at six weeks it’s mostly reduced to the prepregnant size. During this period, mother would not need to take a bathtub but rather shower to prevent infections. Vaginal bleeding is a common thing to find after delivery but intensity of it reduces the third to fourth day, if it intensifies or the newborn mum experiences heavy discharge, she will need to call the healthcare provider. At this period, the mother is not supposed to engage in any sexual intercourse until vagina discharge clears up. The mother must be check her diet and ensure taking more prenatal vitamins and food rich in fiber to prevent constipation.

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, pathophysiological 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.)

Hypothyroidism: This is a condition in which there is an inadequate amount of circulating thyroid hormones triiodothyronine (T3) and thyroid (T4), causing a decrease in metabolic rate that affects all body systems. Most individual that have mild hypothyroidism are not frequently diagnosed, but the hormone disturbance can leads to medical treatment complication.

To prevent the complications in future pregnancy, the mother should be instruct to begin treatment by administration of thyroid hormone replacement therapy and also monitor for cardiovascular compromise like chest pain, palpitations, rapid heart rate, shortness of breath.

Access to the call light

Socks with grips on the bottom of them

Top side rails up.

Matching Id bands

Bed on lowest position

The patient will be discharge on the 03/07/21 with her partner to the house

. She would need to schedule a follow up doctor’s appointment when they go home.

. Avoid heavy lifting and strenuous exercise

. Try to get as much rest as she can as they will be up frequently at night with the baby

.Good nutrition and adequate fluids are necessary for tissue repair, healing, breast feeding and general health.

.Elevate their feet when sitting or lying down and making sure they drink lots of water to help get rid of the excess fluid.

.She can takes shower as many time she want but avoid tub bath or swimming until after postpartum checkup.

. To contact health care provider whenever there is frequency or burning urination, temperature is 100.4 and above, unrelieved pain, no bowel movement for four days or longer.

The patient would need to be educate on the care of newborn:

Breastfeeding, latching on, positioning, mother’s nutrition

Safety: falls, rear facing car seat, safe handling swaddling, baby bath, diapering

When to call the physician: elevated temperature, difficulty breathing, poor appetite, feeding intolerance.

Nursing Diagnosis

Related to

As Evidence By

Rationale (reason for priority)

1

2

3

Parity 2

(Synthroid)

PRN

Route; IV

injection

Every 4 hrs

(BRETHINE)

injection

SQ

PRN

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?