Patient Care Plan

NUR 4545 Women and Newborn Health Nursing

Student Name: _____________________________________________ Date of Care: 12/10/2020

Focus of Care Plan: Newborn

Identifying information : Complete information for newborn AND mother

NEWBORN Initials: C.O Sex: M Birth date: 12/02/2020 Gestational age: 39w 5d Birth weight: 3.65 Kg Age (in hours): 192

APGAR scores at birth (1 and 5 min.): 8 (1min) 9 (5mins) Method of feeding: __________ Blood type: O+ Coombs: __________

Transcutaneous Bili (TCB) or Serum Bili (include hour of life): __________ Glucose: __________

MOTHER Initials: A. O Age: 31 Gravida 1 Para (term) 1 (preterm) 0 (abortions/miscarriages) 0 (living children) 1

LMP: ______ Estimated date of delivery (“due date”): _____ Weeks gestation:39 weeks Prenatal Group B Strep: A+

Other abnormal prenatal labs: __________________ Most recent Hemoglobin and hematocrit: __________ Blood Type: __________

EBL: ___________ Episiotomy or laceration (describe by type and/or degree): __________________________________________

Type of anesthesia used during labor and/or birth (if applicable): __________________________________________

FOR ALL CARE PLANS

Type of birth (highlight or bold): vaginal delivery Cesarean-section not delivered/born yet

Is there history of any high-risk situations or complications to previous pregnancy, labor/birth, or postpartum period? YES NO

If yes, please list: _______________________________________________________________________________________________________

Is there history of any complications to current pregnancy, labor, birth, postpartum, or newborn? YES NO

If yes, please list: _______________________________________________________________________________________________________

Medications ordered for your patient: (add more columns as needed)

Medication:

Drug Category:

Prescribed for:

Dose, route, and frequency

Hep. B

Phytonadione (Vitamin K)

Erythromycin 5mg/gram (0.5%) Ophthalmic ointment

Sucrose (Toot sweet, Sweet ease) 24% oral sol 1 drop

Nursing Diagnoses

List the top three nursing diagnoses for this patient. Use NANDA format (diagnosis, related to, as evidenced by) and place the diagnoses in their priority order. Briefly discuss the rationale for this priority order.

Priority

Nursing Diagnosis

Related to

As Evidenced By

Rationale for Priority Order

(Why is 1st diagnosis first, 2nd diagnosis, second, etc.)

1

2

3

Select the top two nursing diagnoses and complete a work-up table for each. PLEASE NOTE: the two diagnoses must be significantly different from each other to demonstrate maximum learning.

Nursing Diagnosis #1: (WRITE YOUR COMPLETE DIAGNOSIS HERE)

Assessment
(Include all assessment data related to diagnosis)
Patient Outcome
(Desired outcome or evaluation parameters, using S-M-A-R-T)
Nursing Interventions & Rationale
(Specific nursing actions with rationale)
Evaluation
(Was each outcome met or unmet? Why?)
Nursing Diagnosis #2: (WRITE YOUR COMPLETE DIAGNOSIS HERE)

Assessment
(Include all assessment data related to diagnosis)
Patient Outcome
(Desired outcome or evaluation parameters, using S-M-A-R-T)
Nursing Interventions & Rationale
(Specific nursing actions with rationale)
Evaluation
(Was each outcome met or unmet? Why?)
Rev. 8.19