Description
ASSIGNMENT #1:
I Will be uploading 2 files. One of them is a small example named “ASSIGNMENT 1 EXAMPLE NEWBORN CARE MAP” so you can get the main idea and better understand the assignement and the other one is the document that needs to be filled in that is named “Newborn Care Map”.
YOU NEED TO MAKE SURE IT IS ALL ORIGINAL WORK. RESOURCES USED ARE ONY BETWEEN 2018 TO 2023, NOTHING OLDER THAN 2018! PLEASE ADD THE REFERENCES.
ADDITIONAL INSTRUCTIONS:
There are specific aspects of the care map/care plan:
Data collection page
Concept map or care plan page
Pathophysiology and rationale
You will do complete assessments, identify diagnoses, prioritize problems, and then decide on a plan of care (goal and objectives, comprehensive interventions (with rationales, evaluation of expected outcomes, and modifications) for at least three priority diagnoses:
1 Physiologic
1 Psychosocial
1 Health promotion behavior
(Risk for infection & pain will not be acceptable)
NOTE: Integrate at least three references (within past 5 years), to include 1 journal article, 1 textbook, and 1 scholarly and reputable website. No nursing care plan books allowed as the 1 textbook reference but may be used as an additional reference. The student must utilize APA format for pathophysiology citations and references.
THANK YOU!
ASSIGNMENT #2 REVISION
I will attach 2 files. One will be the file you need to use to edit your previous work named “Matrnal Care MaMap”
The second one will be the document with the instructor’s feedback.
You did this assignment yourself not too long ago.
I received a 60% and was asked to do a revision on it.
Please read the instructor’s feedback in order to properly do a revision.
Original work only.
Professional work only please.
References must be only from within the past 5 years.
No references before 2018 can be used. I will attach the document for you to revise as well as a document with the instructor’s feedback.
*******************KEEP IN MIND this patient gave birth at the ambulance. SOME INFO THAT YOU ADDED DID NOT MAKE SENSE SINCE MY PATIENT DELIVERED AT THE AMBULANCE.
Now that you have feedback and examples I expect excellent work,
THANK YOU!
Unformatted Attachment Preview
MATERNAL CARE MAP
PT. INITIALS:
V.A.
AGE: 43
years old
Obstetric History:
Gestational age: 39 + 0
Gravida: 6
Para: 5
Full term: 5
Preterm: 0
Abortions: 1
Living: 5
Obstetrical Risk Factors:
Advanced Maternal Age
Drug use: None
VS: T: 37.1 Degrees Celsius
HR: 71 beats per minute
RR: 16 breaths per minute
B/P: 138/82 mmHg
PAIN ASSESSMENT: 6/10
(patient reporting a lowgrade headache)
LATCH Score: – 8/10
(patient can actively
breastfeed the newborn)
Bonding/Attachment: 10/10
Infant Security: – 10/10
Sitz Bath: -Not indicated at
this time.
Allergies/Medications:
NKDA/NKFA
STUDENT NAME:
LMP: EDC: 09/06/2023
PAST MEDICAL HISTORY:
Medication/Substances in Pregnancy:
None before delivery.
Primary support companion: Mother
Attended Childbirth Classes:
Not attending.
Date of Birth: 08/30/2023
Time of Birth: 11:47am
Type of Birth: Spontaneous Vaginal Delivery
at Ambulance
Labor and Birth History
Length of labor: 7 hours 11 min
Length of ruptured membranes: 1 hour
Medications/Anesthesia used: Epidural anesthesia for pain
management.
Delivery method: Spontaneous vaginal delivery in an ambulance
Dilation/Effacement/Station:
At admission: 3 cm dilated, 60% effaced and -1 station.
At 5 hours in labor: 6 cm dilated, 90% effaced and 0 station.
At delivery: 10 cm dilated, completely effaced and +2 station.
PATIENT INFORMATION
PHYSICAL ASSESSMENT DATA
Respiratory: Bilaterally equal, no wheezing or stridor; Patient denies pain; Rate and tidal volume WNL
Cardiac: Heart sounds clear; capillary refill less than 3 seconds; pulse strong and regular
Gastrointestinal: Bowel sounds active in all 4 quadrants; Patient reports no BM in past 24 hours; No evidence of distension.
Genitourinary: Patient mandatory voiding prior to delivery; Straw-colored urine; full bladder not palpated on postpartum assessment.
Fetal Heart Rate Assessment:
Contractions
FHR
Type of Monitor: Fetal External Monitoring
Type of Monitor: Electronic fetal heart monitoring (EFM)
Frequency: Approximately every 5 minutes
Baseline FHR: 110 bpm
Duration: 10-15 seconds each interval
Variability: 5-25 Beats Per Minute (moderate)
Intensity: 70mmHg
Periodic/episodic changes: No changes noted through labor and
delivery
Resting tone: 10 mm/Hg
Labor Assessment/Interventions: Assessed contractions every 20-30 minutes and monitored maternal vital signs to ensure patient
comfort. Provided hydration and emotional support to encourage the mother through the process. Instructed proper positioning and
mobility techniques for labor progression. Administered epidural anesthesia as needed for pain management. Applied warm compresses
and perineal massage when appropriate for relaxation and comfort measures. Provided education on breastfeeding initiation, skin-toskin contact, newborn resuscitation, immediate postpartum care of both mother and baby, and potential concerns in the first 48 hours.
IV FLUIDS: Lactated
Ringers 125 ml/hr
IV SITE: Right hand
LAB DATA
H/H: 4.5 g/dL / 39.2 %
VDRL/RPR: Negative
Type/Rh: O positive
Rubella: Negative
Blood Glucose: 79 mg/dL
HbsAG: Negative
UA: Clear and pale yellow
HIV: Negative
GBS: Not Tested
SOCIO-CULTURAL FINDINGS:
Culture/ethnicity/language: Hispanic / English and Spanish
Health beliefs: The patient is open to discussing her health beliefs but
does not express any specific preferences during the care process.
Economic/Educational: Middle class; college education.
Spiritual beliefs: No spiritual beliefs requested.
Significant others: Mother present
CARE MAP/CARE PLAN
#1 Nursing Diagnosis
Excessive Postpartum Bleeding
Goal
Rationales
Interventions
Evaluation
1. The patient will remain
hemodynamically stable and achieve
adequate hemostasis with no further
than 500 ml blood loss during the
postpartum period.
1. The patient has advanced
maternal age which can be
associated with an increased risk
for postpartum hemorrhage
(McCance & Huether, 2019)
2. There is a risk of retained
placental fragments that, if not
expelled, can contribute to
excessive bleeding after delivery
(McCance & Huether, 2019)
3. Aging placenta and uterine
atony have been known to
predispose patients to severe
bleeding during the postpartum
period (Gill et al., 2023)
1. Monitor hemoglobin results,
vital signs, and amount of lochial
discharge every two to four hours
for 24 hours following delivery
2. Encourage the patient’s use of
early ambulation activities as soon
as possible and provide assistance
as needed
1. Assess for evidence that the
patient is achieving the desired
outcomes including
documented adequate
hemostasis in the postpartum
time frame and hemodynamic
stability.
#2 Nursing Diagnosis
Risk for Impaired Parent-Child Attachment
Goal
Rationales
1. The patient will be able to
1. The mother has been through
effectively bond with her newborn by the childbirth process before and
the end of the postpartum period.
thus may have established
expectations that differ from her
current experience.
2. Limited preparation due to not
attending childbirth classes
3. Partner alive but not present
which could affect their ability to
connect during bonding times with
their baby (de Waal et al., 2023)
Interventions
Evaluation
1. Encourage holding, cuddling,
and skin-to-skin contact between
mother and child.
2. Ask the father questions about
his experience with the baby for
managed validation to maintain a
successful bond.
1. The patient will show
developmentally appropriate
bonding behavior when
assessed before discharge. 1
week reassessments until goals
are achieved.
#3 Nursing Diagnosis
Antepartum Risk for Ineffective Coping Related to Lack of Childbirth Education
Goal
1. The patient will demonstrate
adequate coping strategies related to
childbirth preparation, knowledge,
and education by the end of her
postpartum stay.
Rationales
Interventions
Evaluation
1. Providing information on labor
and delivery can help reduce stress
levels and improve understanding
(Kuo et al., 2022)
3. Utilizing educational resources
tailored to maternal age can
significantly facilitate learning
outcomes regarding pregnancy
health topics (Kuo et al., 2022).
1. Assess the level of knowledge
regarding physiological processes
and expectations for labor,
delivery, and post-partum care.
2. Discuss available antepartum
services available
3. Provide educational materials
that address recommended
treatments and lifestyle changes
associated with pregnancy
By discharge, the patient will
verbalize understanding of the
antepartum period and will
demonstrate practical coping
strategies with minimal
assistance from healthcare
providers related to pain
management, parental role in
providing child care, and
feeding methods for age
groups.
Pathophysiology & Rationale
Post-partum bleeding refers to a scenario where the mother loses more than 1000 mL with signs of hypovolemia within a day of
delivery (McCance & Huether, 2019). It is caused by the shedding of the lining of the uterus as it gradually contracts back to its prepregnancy size after delivery (McCance & Huether, 2019). The uterus may also be slow to heal or may be affected by an infection,
leading to excessive bleeding (McCance & Huether, 2019). In the case of a 43-year-old mother of 6, there is a significant risk of
excessive post-partum bleeding due to multiple births and her age. Her uterus muscles may have become weaker, impairing
contraction after birth and leading to bleeding (McCance & Huether, 2019). Further, multiple pregnancies increase the risk of
infection (McCance & Huether, 2019). The nurse should be aware of the patient’s risk and engage in activities such as uterine
massage and monitoring post-delivery 9(McCance & Huether, 2019)
References
de Waal, N., Boekhorst, M. G., Nyklíček, I., & Pop, V. J. (2023). Maternal-infant bonding and partner support during pregnancy and
postpartum: Associations with early child social-emotional development. Infant Behavior and Development, 72, 101871.
https://www.sciencedirect.com/science/article/pii/S0163638323000632#:~:text=Fundamental%20to%20health%20practices%
20during,for%20optimal%20maternal%2Dinfant%20bonding.
Gill, P., Patel, A., & Van Hook, J. W. (20123). Uterine atony. Treasure Island (FL): StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK493238/
Kuo, T. C., Au, H. K., Chen, S. R., Chipojola, R., Lee, G. T., Lee, P. H., & Kuo, S. Y. (2022). Effects of an integrated childbirth
education program to reduce fear of childbirth, anxiety, and depression, and improve dispositional mindfulness: A single-blind
randomised controlled trial. Midwifery, 113, 103438.
https://www.sciencedirect.com/science/article/abs/pii/S0266613822001899#:~:text=The%20benefits%20of%20childbirth%20
education,methods%2C%20and%20enhancing%20positive%20childbirth
McCance, K. L. & Huether, S. E. (2019). Pathophysiology: the biologic basis for disease in adults and children (8th ed.). St. Louis,
MO: Mosby/Elsevier.
Ricci, S. S., Kyle, T., & Carman, S. (2021). Maternity and Pediatric nursing. 4th ed.
Philadelphia: Wolters Kluwer Health/Lippincott
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