Postpartum Assessment and Care Plan
Mother’s Initials Age Gravida T P A L
Est Date of Del Delivery Date Time Postpartum Day Type of Delivery Wound
Diet Activity Breast or Formula Feeding Physician’s Initials
Current Physician’s Orders Rationale Relevance for this Client
(include all postpartum orders)
www.mardair.com/adn Nursing Forum Website D:\Docstoc\Working\pdf\d9f22fc0-2be5-499c-8eb0-fcabe86520ff.doc 1
Postpartum Assessment and Care Plan
I. Collection of Data
A. SIGNIFICANT SOCIAL PSYCHOLOGICAL MEDICAL HISTORY
1. SOCIAL
a. education: college educated marital status:
career plans :
b. family (who is living at home, extended family in the area)
c. husband’s or significant other’s career :
2. CULTURAL / RELIGION
a. race: ethnicity: religion
b. effects on postpartum care:
3. HISTORY OF PSYCHIATRIC OR EMOTIONAL PROBLEMS
4. MEDICAL HISTORY (not related to reproductive system)
a. previous illnesses
b. previous hospitalizations
c. previous surgeries
d. family history (genetic disorders, cancer, diabetes)
e. other
______________________________________________________________________________
B. SIGNIFICANT REPRODUCTIVE and OBSTETRICAL HISTORY
1. PREVIOUS SURGERIES / HOSPITALIZATIONS
2. PREVIOUS LABOR AND DELIVERY EXPERIENCES
3. MENSES
a. age of onset of menses b. duration of menses
c. LMP d. abnormalities
4. PRE-NATAL VISITS
a. date of first prenatal visit b. number of visits
5. WEIGHT GAIN
6. MEDICATIONS TAKEN DURING PREGNANCY
www.mardair.com/adn Nursing Forum Website D:\Docstoc\Working\pdf\d9f22fc0-2be5-499c-8eb0-fcabe86520ff.doc 2
Postpartum Assessment and Care Plan
7. BLOOD TYPE
Type: Rh factor:
8. PREPARATION FOR CHILDBIRTH (education)
9. DIAGNOSTIC TESTS DONE DURING PREGNANCY
(include blood type, Rh, RPR, or STS, Rubella, and Hep B, ultrasound exams, genetic studies, all other tests that SHOULD have been
performed based on textbook standards) SEE SUPPLEMENT SHEET
Name Date Results Norms Significance
C. IDENTIFIED MEDICAL , OBSTETRICAL or GENETIC RISK FACTORS
D. EVENTS PRECIPITATINGTHIS HOSPITAL ADMISSION
(why did she come to the hospital when she did : contractions, ruptured membranes, etc.)
_____________________________________________________________________________________
E. LABOR AND DELIVERY
1. LENGTH client normal range evaluation
length first stage 16.8 hours
length second stage 2 hours
length third stage 30 minutes
2. MEDICATIONS identify drug analgesic anesthetic oxytocic
classifications, name, route, dosage , time etc.
first stage
second stage
third stage
www.mardair.com/adn Nursing Forum Website D:\Docstoc\Working\pdf\d9f22fc0-2be5-499c-8eb0-fcabe86520ff.doc 3
Postpartum Assessment and Care Plan
OTHER MEDICATIONS USED:
3. FETUS/NEONATE
FHR range during labor Monitor leads used
Signs of Distress
Gender of Baby: Female Male 1 minute Apgar: 5 minute Apgar
Anomalies: Resuscitation needed other than bulb syringe?
Condition Now:
:
4. MOTHER
Complications during labor and/or delivery?
Her description of the experience?
Her contact with the neonate in the delivery room
(see,touch, hold, etc.)
Support system:
Other Relevant information:
:
F. FIRST 2-3 HOURS POSTPARTUM
complications:
other relevant information:
II. Current General Assessment (See Nursing 112 Med-Surg Assessment Guide)
A. CIRCULATORY
Current Radial Pulse Current Apical Pulse
RATE RHYTHM VOLUME
Pedal Pulses Palpable Range of Pulses during Hospital Stay
Current Blood Pressure Range of Blood Pressure during Hospital Stay
Evidence of Fluid Accumulation (e.g. edema, ascites, respiratory congestion)
lower extremity edema +2 pitting
C/O syncope, dizziness, palpitations C/O SOB , orthopnea C/O Chest Pain
B. TEMPERATURE STATUS
Current Temperature Range of Temperatures during Hospitalization Drugs ordered that affect body temperature
www.mardair.com/adn Nursing Forum Website D:\Docstoc\Working\pdf\d9f22fc0-2be5-499c-8eb0-fcabe86520ff.doc 4
Postpartum Assessment and Care Plan
C. RESPIRATORY STATUS
Current Rate Rhythm Depth Character of Respirations
Ranges during hospitalization: Ease of Breathing:
Respiratory Therapy Treatments Ordered: Pulse Oximetry Reading:
Factors affecting or interfering with breathing Use of Respiratory aids (e.g. oxygen, HOB elevated, ventilation):
Abnormal Symmetry of movements on respiration: Use of Accessory Muscles during respiration
Breath Sounds Presence of Cough
Characteristics of Sputum Smoking Habits
Allergies which may affect breathing Drugs ordered to affect gas exchange
D. MENTAL STATUS
Level of Consciousness Orientation to person, place, time
Ability to Communicate and Understand ideas Appropriate verbal responses
Drugs ordered to affect mental status
E. EMOTIONAL STATUS
Verbal Expression of Feelings (stated concerns, anxieties and fears)
Non – Verbal Expression of Feelings (facial expressions, body language, etc.)
Behavior that indicates how your patient copes with stressful situations?
Any evidence of emotional instability?
Does your Patient’s emotional status affect his / her activity level?
Behaviors that indicate feelings or beliefs about self-concept?
How does your patient relate to you and others?
www.mardair.com/adn Nursing Forum Website D:\Docstoc\Working\pdf\d9f22fc0-2be5-499c-8eb0-fcabe86520ff.doc 5
Postpartum Assessment and Care Plan
F. STATE OF REST AND COMFORT
Current Sleep Pattern Usual Sleep Pattern
Factors interfering with rest and comfort
C/O or signs of pain , discomfort and restlessness
Aids used to relieve pain (excluding meds)
Drugs ordered to promote sleep, rest or comfort
G. SENSORY PERCEPTION
Hearing Vision Pupil Check (PERRLA)
Touch Smell Taste
H. MOBILITY STATUS
Activity prescribed: Activity practiced:
Tolerance of Activity:
good
Ambulation: Transfers:
Use of aids for mobility Limitations on ROM
Muscle strength in extremities
Risk for Injury (e.g. falls) related to mobility status
Interventions done to promote patient safety related to mobility
Drugs ordered to affect mobility:
I. NUTRITIONAL STATUS
Height Weight Desired weight for height and age:
Current Diet Ordered: Allergies
General State of Nourishment (general appearance)
www.mardair.com/adn Nursing Forum Website D:\Docstoc\Working\pdf\d9f22fc0-2be5-499c-8eb0-fcabe86520ff.doc 6
Postpartum Assessment and Care Plan
Problems with Mastication Own Teeth / Dentures
Appetite Presence of Abnormal Thirst
Swallowing Other factors interfering with Nutrition
Use of Intravenous Fluids: Use of Parenteral Nutrition (hyperalimentation)
Drugs ordered to affect nutritional status:
J. ELIMINATION STATUS
Bowel Elimination
Presence of Bowel Sounds Presence of Abdominal Distention
Abdomen soft or firm Frequency of BM’s
Last BM Characteristics of Stool
Passage of Flatus Fecal Incontinence
Presence of Hemorrhoids Rectal Bleeding
Drugs ordered that affect fecal elimination:
Urinary Elimination
Frequency of Voiding Amount per voiding
Color of Urine Odor of Urine
Urinary Uncontinence
C/O dysuria, urgency, pain when voiding Presence of urinary drainage tubes (Foley catheter, nephrostomy tube)
K. STATE OF SKIN AND MUCOUS MEMBRANE
L. FAMILY INVOLVEMENT
III. Assessment Specific to Postpartum Client
A. VITAL SIGNS
Your Client Normal Significance
Temperature 97-100.5
Pulse 60-90
Respiration 16-24
www.mardair.com/adn Nursing Forum Website D:\Docstoc\Working\pdf\d9f22fc0-2be5-499c-8eb0-fcabe86520ff.doc 7
Postpartum Assessment and Care Plan
B. FUNDUS
Present Location in relation to umbilicus:
Expected location and firmness for this postpartum day:
C. LOCHIA
Flow Today rubra / serosa / alba
Expected flow for this postpartum day rubra / serosa / alba
Amount of Flow none / scant / Expected amount for this postpartum day: none / scant /
moderate / heavy moderate / heavy
D. PERINEUM
1. Wound (type): Appearance
Expected Appearance:
Deviations from normal:
2. Describe present care of wound:
Is she complaining of discomfort due to her wound?
If yes, What is being done to decrease this discomfort?
3. Does she have hemorrhoids?
Are hemorrhoids expected at this time?
why?
What is/can be done to reduce discomfort due to hemorrhoids?
4. Other Concerns:
E. BREASTS
1. Describe the appearance and consistency: soft / firm / engorged / painful / redness / lumps / etc.
2. Expected appearance and consistency for this postpartum day?
3. Condition of nipples: red / painful / inverted / cracks
4. Expected condition of nipples for this postpartum day: red / painful / inverted / cracks
5. Deviations from normal:
6. If she is breastfeeding , describe degree of success:
www.mardair.com/adn Nursing Forum Website D:\Docstoc\Working\pdf\d9f22fc0-2be5-499c-8eb0-fcabe86520ff.doc 8
Postpartum Assessment and Care Plan
7. If she is breastfeeding , describe present breast care being given:
8. If NOT breastfeeding, any anti-lacating drugs administered:
9. Does this patient need a referral to a lactation consultant?:
F. ELIMINATION
1. Time of first voiding after delivery: Amount:
2. Expected length of time between delivery and first voiding:
3. Deviations from normal:
G. IF DELIVERED BY C/S
1. Condition of incision / dressing:
2. Deviations from normal:
3. Type of incision: classical / low cervical transverse
4. Abdomen: soft / firm / distended / non-distended
Bowel Sounds: yes / no / # of quadrants Flatus?
5. Urinary catheter:
6. I.V.: type / flow / arm / site / patency
7. Lungs: clear / rales / wheezing / left / right / bilaterlally
8. Legs: tenderness / Homan’s sign
9. Activity: up as tolerated / bedrest / bathroom privileges
10. Level of comfort: pain / intensity / location
H. BONDING
1. Is mother at “taking in” or “taking hold” phase?
Support answer with illustration:
Expected phase for this postpartum day:
Comments:
www.mardair.com/adn Nursing Forum Website D:\Docstoc\Working\pdf\d9f22fc0-2be5-499c-8eb0-fcabe86520ff.doc 9
Postpartum Assessment and Care Plan
2. Identify factors which might be significant in interfering consider prenatal, labor and delivery, support systems, gender of child,
with bonding between this mother and baby: comfort of mom, etc.
3. Identify signs that indicate a healthy mother/baby remember baby should be included.
relationship:
4. Identify some signs that indicate this mother and baby are
having some difficulty establishing a positive relationship:
www.mardair.com/adn Nursing Forum Website D:\Docstoc\Working\pdf\d9f22fc0-2be5-499c-8eb0-fcabe86520ff.doc 10
Postpartum Assessment and Care Plan
I. CURRENT MEDICATIONS include PRN medications
Name of Drug Dose Frequency Side Effects Nursing Implications
www.mardair.com/adn Nursing Forum Website D:\Docstoc\Working\pdf\d9f22fc0-2be5-499c-8eb0-fcabe86520ff.doc 11
Postpartum Assessment and Care Plan
IV. Nursing Diagnoses
(List Actual and Potential Problems)
(include “related to” and “as manifested by” statements – these can be wellness related)
A minimum of 5 diagnoses are required ; Additional diagnoses constitute a stronger care plan
____a.
____b.
____c.
____d.
____e.
www.mardair.com/adn Nursing Forum Website D:\Docstoc\Working\pdf\d9f22fc0-2be5-499c-8eb0-fcabe86520ff.doc 12
Postpartum Assessment and Care Plan
Note this extra page has been inserted for you as a reminder to include any additional antepartal testing information or
addendum to your information collection.
Please note that some computer printers may not tranform the last two pages into landscape format (see below). Be sure to
verify that the printing will occur as it appears on your monitor screen by clicking on the print preview button. That’s the
button with the piece of paper with the magnifying glass on it.
Portrait Format Landscape Format
www.mardair.com/adn Nursing Forum Website D:\Docstoc\Working\pdf\d9f22fc0-2be5-499c-8eb0-fcabe86520ff.doc 13
Postpartum Assessment and Care Plan
IV. NURSING CARE PLAN AND EVALUATION
NURSING DIAGNOSIS PATIENT GOAL AND NURSING INTERVENTION RATIONALE EVALUATION
OUTCOME CRITERIA
Diagnosis Long-term Goal: 1. 1. Objective Data:
Related to: 2. 2.
Manifested by: Expected Outcome Criteria: 3. 3. Subjective Data:
4. 4.
5. 5.
6. 6. Conclusion:
7. 7.
8. 8.
9. 9.
10. 10.
11. 11.
12. 12.
IV. NURSING CARE PLAN AND EVALUATION
NURSING DIAGNOSIS PATIENT GOAL AND NURSING INTERVENTION RATIONALE EVALUATION
OUTCOME CRITERIA
Diagnosis Long-term Goal: 1. 1. Objective Data:
Related to: 2. 2.
Manifested by: Expected Outcome Criteria: 3. 3. Subjective Data:
4. 4.
5. 5.
6. 6. Conclusion:
7. 7.
8. 8.
9. 9.
10. 10.
11. 11.
12. 12.
www.mardair.com/adn Nursing Forum Website D:\Docstoc\Working\pdf\d9f22fc0-2be5-499c-8eb0-fcabe86520ff.doc 14
Postpartum Assessment and Care Plan
IV. NURSING CARE PLAN AND EVALUATION
NURSING DIAGNOSIS PATIENT GOAL AND NURSING INTERVENTION RATIONALE EVALUATION
OUTCOME CRITERIA
Diagnosis Long-term Goal: 1. 1. Objective Data:
Related to: 2. 2.
Manifested by: Expected Outcome Criteria: 3. 3. Subjective Data:
4. 4.
5. 5.
6. 6. Conclusion:
7. 7.
8. 8.
9. 9.
10. 10.
11. 11.
12. 12.
IV. NURSING CARE PLAN AND EVALUATION
NURSING DIAGNOSIS PATIENT GOAL AND NURSING INTERVENTION RATIONALE EVALUATION
OUTCOME CRITERIA
Diagnosis Long-term Goal: 1. 1. Objective Data:
Related to: 2. 2.
Manifested by: Expected Outcome Criteria: 3. 3. Subjective Data:
4. 4.
5. 5.
6. 6. Conclusion:
7. 7.
8. 8.
9. 9.
10. 10.
11. 11.
12. 12.
www.mardair.com/adn Nursing Forum Website D:\Docstoc\Working\pdf\d9f22fc0-2be5-499c-8eb0-fcabe86520ff.doc 15