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Maternity Care Plan (Postpartum)

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NORTH CAROLINA CENTRAL UNIVERSITY
DEPARTMENT OF NURSING
4003 Modified Nursing Care Plan
You must submit the clinical tool with the care plan

Student Name : Crystal Stephenson Date: October 27, 2012
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Patient Summary: J.M. is a 25 year old Caucasian female G1 T1 A0L1 who began Stage 1 of labor 10/21/12 at 2300. She presented at Wake Med 10/22/12 at 1655 with SROM and contractions. She received treatment for GBS after testing positive. She delivered a baby girl weighing 6lbs 6oz 10/22/12 at 2057 with the assistance of a vacuum. Baby’s AGARs were 8/9. Client received an epidural during labor. Her estimated blood loss was 400 ml. She received a 3rd degree laceration to her perineal area during labor and has not been able to void since even when she has had the urge to. An indwelling foley was placed 10/23/12 at 1230 to relieve urinary retention and bladder distension. 600 ml of urine was collected 10/23/12 at 1800. She was prescribed Dermoplast 20% to use while providing peri care to relieve the discomfort and swelling of her perineal area. Client is currently breast feeding. She received education about different feeding positions and has demonstrated a good latch with the baby in the football hold. Client is allergic to Macrobid and experiences hives and itching when exposed. Her abnormal labs were high WBC [24.4] and low platelets [145]. WBCs are normally high after labor but will monitor client for signs of infection. Her low platelet count puts her at risk for bleeding. Student nurse provided education to patient about precautions to prevent bleeding and signs of hemorrhaging to watch for. Her fundus was below the umbilicus when assessed. She changes her peripads 3 to 4 times per day. Student nurse provided education about breast care after breast feeding and provided breast shells to help her nipples air dry while maintaining her modesty. Good job with stating the client’s historical data.
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Pathophysiology (Include Normal Physiology, identify the Physiological Alteration, identify signs and symptoms).
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Normal Physiology: Postpartum the body is primarily trying to achieve homeostasis. This period is sometimes referred to as the fourth trimester of pregnancy, puerperium. The uterus is trying to contract back down to its natural state. To achieve homeostasis the hormone, oxytocin, is released. This contracts the uterus and prevents blood flow to the uterus preventing hemorrhaging. The fundus should be palpated midline and at the umbilicus at twelve hours postpartum, falling 1 to 2 cm per day. (Lowdermilk, Perry, Cashion, & Alden, 2012) After birth, the lining of the uterus is released. This is called lochia. Two hours after birth it should be like a heavy period and decrease over time lasting up to eight weeks. The vagina is stretched during birth but gradually decreases in size regaining it former shape and size in about 3 to 4 weeks. Estrogen levels and progesterone levels decrease after birth causing breast engorgement and diuresis of the extracellular fluid the mother obtained while pregnant. Due to the trauma of birth and the effects of the anesthesia the urge to void is decreased. The decreased urge to void and the diuresis can lead to bladder distention. In breast feeding mothers, the breasts produce colostrum. The baby’s feeding increase prolactin levels which increase milk production about 72 hours to 96 hours postpartum. The breasts may become engorged at this time. During pregnancy the woman is a state of hypervolemia that allows for blood loss during pregnancy. Postpartum plasma volume returns to normal within the first few days through diuresis and the extravascular fluid returns to the intravascular space. During the puerperium stage for the first ten days the woman’s white blood cell count is normally 20,000-25,000. (Lowdermilk, Perry, Cashion, & Alden, 2012)
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Pathophysiology: An irregular tear in the body’s tissues is called a laceration. In the child birthing process these can occur in the cervix, vagina, and perineum. They are rated classified by the depth of tissue they encompass. First degree laceration extends through the skin and superficial layers to the muscle. Second degree laceration extends through the muscles of the perineal body. Third degree laceration continues through the anal sphincter muscle. Fourth degree laceration involves the anterior rectal wall. (Lowdermilk, Perry, Cashion, & Alden, 2012) The client suffers from a third degree laceration and has been prescribed to relieve swelling and discomfort. Has been prescribed to soften her stool and making it easier to pass. The client has been unable to void increasing her bladder distension displacing her uterus placing her at risk for bleeding. A foley was placed to reduce bladder distension. You have researched this area well.
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Growth and Development Assessment: (Erickson Developmental Stages supported with specific objective behavior indicators)
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J.M. is 25 years old and is currently in Erikson’s Intimacy versus Isolation stage. During this stage it is important for young adults need to form intimate, loving relationships with other people. Success in this stage leads to strong relationships, while failure results in loneliness and isolation. (Potter & Perry, 2004) J.M. is currently married and her husband seems very supportive and they seem to have a healthy relationship. They have family that visited them in the hospital that could possibly provide support in times of physical and emotional turmoil, which is possible during this time of transition in their lives. She was very amicable and open to communication. J.M. sees to be headed towards success in this stage. I provided the new parents with education and tips on how to sooth the baby and normal child development during the first few months to help prepare them for this transition stage.

NURSING DIAGNOSIS: (Identify the nursing diagnoses for the client. ALL those determined from the data collected.)

HIGH PRIORITY: 1. Urinary Retention related to perineal trauma and effects of anesthesia AEB client’s inability to void within first eight hours postpartum and inability to urinate even when client feels the urge to void. 2. Knowledge Deficit related to breast feeding AEB client expressing interest in learning, client stating information she has previously learned, and client being receptive to coaching and instruction by student nurse on topic. 3. Risk for Infection, risk factors: 3rd degree laceration to the perineal area during labor, indwelling catheter, and increased WBCs (24.4). Good job with stating nursing diagnoses.
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Teaching Needs (include home care issues/needs- discharge instructions):
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Breast care
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Teach client signs and symptoms of engorgement and mastitis.
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Teach client to place breast milk on nipples and allow breast to air dry.
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Provided nipple shells to allow breasts to air dry will maintaining maternal modesty.
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Teach client to alternate breasts when breast feeding
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Teach client to allow infant to breast feed for 20-30 mins per breast.
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Teach client not to allow infant to have a pacifier for 2-3 weeks until milk production is established and infant has shown adequate weight gain.
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Teach client feeding pattern of new infants.
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Child Development
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Teach milestones infant might be meeting within first three months of life.
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Teach client to provide stimulation during infant’s wakeful periods with her face 8-10 inches away.
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Teach client to talk and sing to infant.
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Teach client about period of Purple Crying and proper coping methods.
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Teach client methods to soothe infant.
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Infection Prevention
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Teach client signs and symptoms of infection.
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Teach client to clean perineal area with bottle provided
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Teach client to wash hands before cleaning perineal area and after using the bathroom
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Teach client to obtain as much rest as allowed and eat a well-balanced diet.
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Teach client to limit stress as much as possible because it weakens the immune system.
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Urinary Elimination
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Teach client signs and symptoms of a UTI.
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Teach client to fully empty bladder when voiding and trying voiding again even after flow has stopped.
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Teach client to maintain proper hydration.
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Acute Pain
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Teach client to stay ahead of the pain, not to wait until the pain was unbearable before asking for medication
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Teach client to stay well hydrated to prevent constipation that happens with opioid use.
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Teach client not to walk around with the baby while using opioids to suppress pain.
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Well done!
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NORTH CAROLINA CENTRAL UNIVERSITY
DEPARTMENT OF NURSING
NURSING CARE PLAN

Student: Crystal Stephenson Client ID (initials): J.M. Location: Wake Med 4C23 Date: October 23, 2012

Assessment Data(pertinent to this Nursing Diagnosis)Objective:Indwelling Catheter inserted 10/23/12 @ 1200 Urine output 600 ml @ 1800 (over 6 hour time span from 1200-1800 hrs) goodSubjective:Client states that she had the urge to void but was unsuccessful in the three times she attempted post-partum.goodObjective: Trauma to nipples caused by improper technique used to delatch the babyObserved improper latchDemonstrated proper feeding holds and latch with education.Subjective: Client asks for assistance with breast feedingClient follows directions wellClient discusses information she has already learned about breast feeding. Good job with Obj and Subj data.Risk Factors: Objective: 3rd degree lacerationVaginal birthIndwelling catheterWBC: 24,000 | Nursing Diagnosis/Collaborative Problem Urinary Retention related to perineal trauma and effects of anesthesiaKnowledge Deficit r/t breast feedingRisk for infection | Expected Client Outcomes(GOALS)Short/Long TermShort Term Goal: Client will experience correction or alleviation of storage of urine during my shift. (Ackley & Ladwig, 2011)Long Term Goal: Client will demonstrate consistent ability to urinate when desire to void is perceived or via timed schedule; measured urinary residual volume is < 200 to 250 ml or 25 % of total bladder capacity (voided volume plus urinary residual volume) within 48 hours. (Ackley & Ladwig, 2011)Short Term Goal: Will demonstrate proper breast feeding techniques.Long Term Goal:Baby will regain birth weight within three weeks.Short Term Goal: Client will demonstrate appropriate hygienic measures such as hand washing, oral care, and perineal care during my shift.goodLong Term Goal:Client will remain free of signs of infection for a week. | Nursing Interventions/Implementation S.T. Independent: Teach the client who is unable to void specific strategies to manage this potential medical emergency as follows: attempt urination in complete privacy, place the feet solidly on the floor, if unable to void using these strategies take a warm sitz bath or shower and void (if possible) while still in tub or shower. (Ackley & Ladwig, 2011) good S.T. Collaborative: Remove the indwelling urethral catheter at midnight in the hospitalized client to reduce the risk of acute urinary retention. (Ackley & Ladwig, 2011) S.T. Dependent: Insert an indwelling catheter for the individual with urinary retention who is not suitable candidate for intermittent catheterization. L.T. Independent: Complete a bladder log including patterns of urine elimination, urine loss (if present), nocturia, and volume and type of fluids consumed for a period of 3-7 days. L.T. Collaborative: Determine the urinary residual volume by catheterizing the client immediately after urination or by obtaining a bladder ultrasound after micturition. L.T. Dependent: Consult with the physician concerning eliminating or altering medications suspected of producing or exacerbating urinary retention. S.T. Independent: Provide client with education about proper breast feeding techniques. (Lowdermilk, Perry, Cashion, & Alden, 2012) S.T. Collaborative: Shift nurses working together to provided client with proper support and knowledge. (Lowdermilk, Perry, Cashion, & Alden, 2012) good S.T. Dependent: Consult Lactation specialist for a follow up visit if needed. (Lowdermilk, Perry, Cashion, & Alden, 2012) L.T. Independent: Will provide patient education about the feeding patterns of newborns. (Lowdermilk, Perry, Cashion, & Alden, 2012) L.T. Collaborative: Client will follow up with home lactation specialists or breast feeding support group. (Lowdermilk, Perry, Cashion, & Alden, 2012) good L.T. Dependent: Client will follow up with baby’s pediatrician after discharge from hospital for initial well check up. (Lowdermilk, Perry, Cashion, & Alden, 2012) S.T. Independent: Ensure the client's appropriate hygienic care with handwashing; bathing; oral care; and hair, nail, and perineal care performed by either the nurse or the client. S.T. Collaborative: If a urinary catheter is necessary, follow catheter management practices: All indwelling catheters should be connected to a sterile, closed drainage system (i.e., not broken), except for good clinical reasons. Cleanse the perineum and meatus twice daily using soap and water. S.T. Dependent: Recommend responsible use of antibiotics; use antibiotics sparingly. L.T. Independent: Use appropriate “hand hygiene” (i.e., handwashing or use of alcohol-based hand rubs). L.T. Collaborative: When using an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry. Note that the volume needed to reduce the number of bacteria on hands varies by product. L.T. Dependent: Note and report laboratory values (e.g., white blood cell count and differential, serum protein, serum albumin, and cultures). good | Scientific RationaleS.T. Independent: Attempting urination in complete privacy and placing the feet solidly on the floor help relax the pelvic muscles and may encourage voiding. Warm water also stimulates the bladder and may produce voiding; the cooling experienced by leaving the tub or shower may again inhibit the bladder (Gray, 2000b). S.T. Collaborative: Removal of indwelling catheters in clients undergoing urologic surgery at midnight offers several advantages to “morning removal,” including a larger initial voided volume and earlier hospital discharge with no increased risk for readmission compared with those undergoing morning removal (Griffiths, Fernandez, & Murie, 2004).Your rationales support your nursing interventions.S.T. Dependent: An indwelling catheter provides continuous drainage of urine; however, the risks of serious urinary complications with prolonged use are significant (Weld et al, 2000). L.T. Independent: The bladder log provides an objective verification of urine elimination patterns and allows comparison of fluids consumed versus urinary output during a 24-hour period (Nygaard & Holcomb, 2000).L.T. Collaborative: Although catheterization provides the most accurate method to determine urinary residual volume, it is invasive, produces discomfort, and carries a risk of infection (Gray, 2000b). Documentations are present.L.T. Dependent: Observational studies suggest that medications may play a role in approximately 10% of all cases of urinary retention. The most commonly implicated drug classes include antipsychotics, antidepressants, anticholinergic respiratory agents, opioid analgesics alpha-adrenoceptor agonists, benzodiazepines, nonsteroidal antiinflammatory drugs, antimuscarinics, and calcium channel blockers (Verhamme et al, 2008). S.T. Independent: Many new mothers need education about breastfeeding to ensure success. (Lowdermilk, Perry, Cashion, & Alden, 2012) S.T. Collaborative: Breastfeeding is sometimes difficult and takes practice on the mom and newborn’s part. (Lowdermilk, Perry, Cashion, & Alden, 2012) S.T. Dependent: Lactations specialist can provide special interventions for mothers with nipple issues or babies with latch problems. (Lowdermilk, Perry, Cashion, & Alden, 2012) L.T. Independent: Many new mothers do not understand the anatomy of a newborn, how their milk is produced, and the newborns feeding patterns. This leads to them giving up prematurely because they think they are not producing enough milk to satisfy the baby. (Lowdermilk, Perry, Cashion, & Alden, 2012) good L.T. Collaborative: It’s effective to have a follow up visit to answer any questions that might have arose after discharge. The support group is an excellent source for information and encouragement. (Lowdermilk, Perry, Cashion, & Alden, 2012) L.T. Dependent: Breastfeeding newborns tend to lose weight initially but regain lost weight within a few weeks. (Lowdermilk, Perry, Cashion, & Alden, 2012) good S.T. Independent: Daily showers or baths can help to reduce the number of bacteria on the client's skin. The oral cavity is a common site for infection (Coughlan & Healy, 2008). good S.T. Collaborative: Health care-acquired UTIs account for up to 40% of all hospital-acquired infections, with 80% of these associated with the use of urinary catheters (Hampton, 2004). S.T. Dependent: Widespread use of certain antibiotics, particularly third-generation cephalosporins, has been shown to foster development of generalized beta-lactam resistance in previously susceptible bacterial populations (Tillotson, Blondeau, & Carroll, 2007). good L.T. Independent: Meticulous infection prevention precautions are required to prevent health care-associated infection, with particular attention to hand hygiene and standard precautions (CDC, 2002; Gould, 2004). L.T. Collaborative: By introducing the use of hand rubbing with an alcoholic solution, there was significant improved hand-cleansing compliance (Girou & Oppein, 2001). L.T. Dependent: The white blood cell count and the automated absolute neutrophil count are better diagnostic tests for adults and most children (Cornbleet, 2002). | EvaluationShort/Long TermShort Term: Goal was met. Collected 600 ml of urine from foley. Will continue to provide teaching on proper perineal care to prevent infection from the catheter and how to stimulate voiding for when the catheter is removed. Long Term: Goal was not met due to the time restraints of clinical. I was not able to evaluate the effectiveness of our interventions. These interventions should continue with the goal and interventions being assessed with each shift change and changed accordingly to help the client return to optimal health and independence.goodShort Term Goal was MET. Client was able to demonstrate proper feeding holds and breast feeding techniques. She stated that there was no pain with latching and unlatching. She stated she was comfortable while breastfeeding. Will continue to provide interventions and educate where deficits are identified.Evaluation column looks appropriate.Long Term Goal was NOT MET. Due to time constraints of only being with the client five hours I was not able to assess the baby’s weight. However I would have continued to provide interventions and followed up with a telephone consultation at a one week and three week interval to assess situation and assess intervention accordingly. goodShort Term Goal was met. Client was able to demonstrate proper care of perineum site using squirt bottle provided. She was able to state the proper uses and indications for the Tucks pads and Dermoblast. Client was able to demonstrate proper hand hygiene. Will continue with interventions and work towards long term goal. goodLong Term Goal was not met. I was not able to assess whether or not long term goal was met due to my limited time with the client. However, I would have continued to applying intervention and educate client on proper care and signs and symptoms of infection. I would assess the client and evaluate the interventions appropriately to help meet the goal. |

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REFERENCES: (ATTACH A SEPARATE PAGE IF NECESSARY USING APA FORMAT)
Ackley, B., & Ladwig, G. (2011). Nursing Diagnosis Handbook: An Evidence Based Guide to Planning Care. St. Louis, Missouri: Mosby Elsevier.
Lowdermilk, D. L., Perry, S. E., Cashion, K., & Alden, K. (2012). Maternity & Women's Health Care 10th Edition. St. Louis: Elsevier.
Potter, P., & Perry, A. (2004). Fundamentals of Nursing: 6th Edition. St. Louis, Missour: Mosby Elsevier.
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Crystal,
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It is obvious you spent time thinking and researching your care plan.
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Good job!
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15/15 points BBrown

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