Postpartum Nursing Process
Instructions:
1. Complete the Postpartum Assessment Below
2. Describe in detail support systems, interventions, adaptive behaviors.
3. Compile three (3) or more nursing diagnoses with assistance from instructor or formulate your
own.
4. Complete a nursing process (care plan) for the priority diagnosis using the attached format.
a. Include objective and subjective supportive data to validate the nursing diagnosis.
b. Write a goal(s) that is measurable by including AEB. State whether goal was or was not
met. If not met, state how you would revise the plan of care to achieve the goal.
c. Include interventions from the text, modules, or those learned while caring for the
patient.
d. Evaluation needs to be thorough. Evaluate the interventions and the goal(s). Evaluation
should reflect client assessment data. Do not restate the interventions used.
5. Cite all references for interventions and rationales at the end of the care plan.
Student’s Name: Carrie Maxwell
Date: 10/11/19
Pt’s Age: 38 - AMA
Time: 1617 (4:17PM)
Delivery Date: 10/09/2019
PSYCHOSOCIAL:
Maternity History:
Gravida: 1 Para: 1
T (Term) = 1
P (Pre-term) = 0
A (Abortion) = 0
L (Living) = 1
Expected date of delivery: 10/24/2019
Gestation when prenatal care began: 7.1 weeks (7 weeks 1 day)
Complications /Significant history during this pregnancy:
The patient had no complications during her pregnancy. She did have problems
conceiving however. In March of 2016 the patient and her husband began trying for a baby
without success. In May of 2017 they began seeing a fertility specialist. The patient was
diagnosed with Endometriosis in June of 2017.
Endometriosis is the growth of uterine lining tissue outside of the uterine cavity. It can
cause tubal adhesions, painful menstrual periods, and painful intercourse which can lead to
dysmenorrhea, chronic pelvic pain, and infertility. The cause of Endometriosis is unknown but
some research suggests genetics may play a role, as well as environmental factors (like
pesticides and growth hormones in the foods we eat) and hormones within the body. It can
range from mild to severe and is usually diagnoses when a woman is in her late 20’s to 30’s –
during reproductive years because the misplaced tissue is responsive to hormones. The
endometrial tissue that grows outside the uterus responds exactly like the tissue inside the
lining of the uterus. The tissue grows and changes during the follicular and luteal phases and
then sheds during menstruation. The growth and shedding of the endometrial tissue outside of
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the uterus occurs in a closed cavity so it puts pressure and pain on the surrounding tissues.
Prostaglandins are also released by the endometrial lesions during menstruation which causes
contractions and irritates nerve endings resulting in additional pain.
Labs: Blood type _______ RPR _______ HIV ______ Hep B SAg _______ GBS ______
Rubella________
Labor:
Spontaneous: _
Augmentation: _____ Induction Reason: ________________
Delivery:
Spontaneous _______Forceps:___ Vacuum Extraction:
Episiotomy: Type:
__ Lacerations:
______
C-Section Reason: _____________________________
Anesthesia: ______________________________________
Analgesia: _______________________________________
Identified postpartum risk factors related to the labor process:
Psycho/social:
Mothers stated impression about labor and birth experience:
Support system: (marital status, household members, significant others, family who can help
mother when home, etc.)
Parent & family interactions (bonding) with the baby:
Ethnic group/Cultural factors (include specific considerations such as religion, physical
characteristics, race, ethnicity, language, age, family, socio-economic, education/profession,
nutrition, other-drugs, CPS, abuse, infertility, fetal demise, NICU, etc):
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Rubin’s stage: Taking-in, Taking-hold (behaviors to indicate which one your pt. is in) and mother’s
adaptive behaviors.
Provide DETAILED BUBBLE Assessment findings and pertinent information. ***Include related
NURSING INTERVENTIONS, ALL TEACHING DONE, PATIENT EDUCATION and MEDICATIONS with
dosing information, and laboratory findings for each section below. ***
Breast (Indicate breast/bottle feeding and a description of infant feeding):
Uterus (include height & tone):
Bladder (ability to void/foley/urine):
Bowel (include abdominal assessment/flatus):
Lochia/Lacerations/episiotomy:
Extremities/Epidural/Spinal:
Regulatory/Rest:
Safety:
Nutrition
Oxygenation/ Circulation assessment findings (labs & vital signs):
EBL: ________ml
(Include pre & post delivery Hbg/Hct values and compare with EBL)
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Develop three (3) nursing diagnoses and complete a nursing process (care plan)
for the priority postpartum diagnosis using the attached format.
a. Include objective and subjective supportive data to validate the nursing diagnosis.
b. Write goal(s) that are measurable by including AEB. State whether or not the goal was met. If
the goal was not met, state how you would revise the plan of care to achieve the goal (if
applicable).
c. Include interventions from the textbook, lecture modules, and observed while caring for the
patient.
d. Evaluate each intervention and the goal(s) by using patient assessment data. Do not restate
interventions.
e. Nursing diagnoses must include a related to (RT) and supportive data (AEB) statement. “Risk
For” Nursing diagnoses must include a related to (RT) but do not have an AEB.
1.
2.
3.
Postpartum Nursing Process
Priority Nursing
Diagnosis
Goal/Outcome
Supportive Data
(AEB)
Goal/Outcome
Attainment
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Nursing Interventions
Rationale
Evaluation of
Intervention
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Nursing Interventions
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Rationale
Evaluation of Intervention
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