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 informationÂ : Complete information section for MOTHER on Labor Care Plan
Complete information sections for MOTHER and NEWBORN on Postpartum and Newborn Care Plan
MOTHERÂ 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: PositiveÂ Did mom receive antibiotics in labor: Yes
Abnormal prenatal test results:Â Not KnownÂ 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
NEWBORNÂ Initialsâ€™ 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:Â 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): DiagnosisÂ PainÂ 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
Interventions/Implementations and Rationale
(specific nursing actions- MUST include a rationale with each intervention)
(INCLUDE at LEAST 3 INTERVENTIONS AND RATIONALES)
(include whether outcome was met, partially met or unmet)
If the outcome is â€œunmetâ€ what is your plan to meet outcome in the future?
Interventions and Rationales for Outcome #1:
Evaluation for Outcome #1:
Interventions and Rationales for Outcome #2:
Evaluation for Outcom
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