Problem Based Care Plan and Concept Map

Problem Based Care Plan and Concept Map
Please complete a Problem Based Care Plan and Concept Map for Routine Post Partum I uploaded the template and the case study
Violet is a 21 y/o G1P1 who delivered a preterm male infant via c/s secondary due to a breech presentation born at 35 weeks weighing 5lbs 3oz with APGAR 7/9. The baby was born 1 hour ago, and the patient was moved to her postpartum room following an uncomplicated early postpartum recovery period. The baby is currently in the NICU for observation. No intraoperative complications, EBL of 1000 ml., low transverse incision. The patient had an unknown GBS status and was given prophylactic PCN during labor. Violet has chosen to breastfeed.
Violet is a ½ PPD smoker and smoked throughout her pregnancy. Violet is a single mother with minimal family support.
Early postpartum assessment (first hour): Patient bleeding moderate, lochia rubra, no clots noted, incision well approximated and intact without erythema or discharge.
Prenatal history: Violet had an uneventful pregnancy and was compliant with prenatal care since 6 weeks gestation. All prenatal labs WNL. Blood type O+.
Med/Surg Hx: Unremarkable
Family Hx: Unremarkable
Allergies: NKA
Medications:
Epidural morphine 2-3 mg post-delivery
PNV daily
Colace daily
Iron Daily for Hgb less than 11.0 mg/dl
Ibuprofen 800mg PO q 4-6 hours PRN pain
Oxycodone 5-10 mg PO q 4-6 hours PRN breakthrough pain. Pain less than 4/10 5mg, pain greater then 4/10 10 mg
PP CBC: Not resulted yet.
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Solution
Problem-Based Care Plan Worksheet
What assessment data does the nurse find as pertinent (recognize cues)?
• Patient bleeding moderate- EBL of 1000 ml which is within the normal range for C/S.
• lochia rubra, which is normal after delivery,
• All prenatal labs were within normal limits.
• No intraoperative complications incision well approximated and intact without
erythema or discharge
What is the disease process causing these assessment findings (analyze cues)?
• The patient had a C/S due to a breech presentation at 35 weeks and is undergoing a
normal recovery process.
What is the main problem with the patient the nurse can treat (prioritize hypotheses)?
• Normal post-partum recovery
What is the goal for the patient (generate solutions & take action)? create specific,
measurable, achievable, realistic, and timetable (smart) outcomes.
• The patient will continue to exhibit normal vital signs.
• The patient will report decreased pain and discomfort.
• The patient will exhibit increased knowledge on post-partum care after a c/s.
What interventions will the nurse implement when caring for this patient (generate
solutions & take action)? include the evidence. list interventions in order of priority.
include collaborative and nurse?initiated interventions
• Frequently monitor the patient’s vital signs and the surgical wound to ensure there is
no excessive bleeding or abnormal deviations in vital signs- Vital signs provide an
essential indication about patients’ health, especially after surgeries. Signs such as heart
rate, blood pressure, temperature, and respiratory rate can provide essential information
on the possibility of infections and can also detect pain and discomfort. For example,
increased breathing rate and hypertension indicate acute pain.
• Administer the current medications as required to control pain- the patient is currently
under medications including Epidural morphine 2-3 mg post-delivery, PNV daily,
Colace daily, Iron Daily for Hgb less than 11.0 mg/dl, Ibuprofen 800mg PO q 4-6
hours PRN pain, Oxycodone 5-10 mg PO q 4-6 hours PRN breakthrough pain. Painless
than 4/10 5mg, pain greater than 4/10 10 mg, and therefore it will be important to
ensure that the patient does not miss the medications to control pain and maintain iron
levels.
• Encourage the patient to verbalize feelings of pain – the experience of pain is
subjective, and patients experience it differently; it would therefore be important to
encourage the patient to express themselves if they are uncomfortable or in pain.
• Educate the patient on post-partum care practices following a c/s – providing sufficient
information to the patients after a c/s on how to meet their health needs and that of
their babies can lead to higher satisfaction with the post-partum stay (Erickson et al.,
2020).
3
How will the nurse evaluate the patient’s response (evaluate outcomes)? and what was
the patient’s response to the interventions?
• Observe for symptoms of pain and discomfort and complaints from the patients.
• Evaluate the patient level of knowledge through a series of questions to determine their
knowledge levels.
• Evaluate the vital signs trends.
What other problems could the nurse link to this patient problem?
• Iron deficiency
CONCEPT MAP WORKSHEET
Describe disease process affecting patient (include pathophysiology of disease process
• The patient had a C/S due to a breech presentation at 35 weeks and is undergoing a
normal recovery process.
Diagnostic tests (Reason
for Test and Results)
Patient information including
priority patient problem(s)
Assessment findings
• Complete blood
count (CBC) (Normal
hemoglobin levels for
women are between
11.6 to 15g/dl, levels
lower than this can
indicate anemia.)
EBL for the patient
was 1000ml, which is
within the normal
range; however, it is
important to monitor
hemoglobin levels to
assess for iron
deficiency.
• Violet is a 21 y/o G1P1
who delivered preterm
due to a breech
presentation at 35
weeks
• #1 Normal post-partum
recovery
• #2Iron deficiency
• No intraoperative
complications
• Incision well
approximated and
intact without
erythema or discharge
• Patient bleeding
moderate- EBL of
1000 ml
• Prenatal labs were
within normal limits.
• Lochia rubra
Plan of care/interventions
• Frequently monitor the patient’s vital signs and the surgical wound to ensure no
excessive bleeding or abnormal deviations in vital signs- Vital signs provide an
essential indication about patients’ health, especially after surgeries.
• Administer the current medications as required to control pain. The patient is currently
under medication including Epidural morphine 2-3 mg post-delivery, PNV daily,
Colace daily, Iron Daily for Hgb less than 11.0 mg/dl, Ibuprofen 800mg PO q 4-6
hours PRN pain, Oxycodone 5-10 mg PO q 4-6 hours PRN breakthrough pain. Pain
less than 4/10 5mg, pain greater than 4/10 10 mg
• Educate the patient on post-partum care practices following a c/s – providing sufficient
information to the patients after a c/s on how to meet their health needs and that of
4
their babies can lead to higher satisfaction with the post-partum stay (Erickson et al.,
2020).
5
References
Erickson, E. N., Lee, C. S., & Carlson, N. S. (2020). Predicting postpartum hemorrhage after
vaginal birth by labor phenotype. Journal of midwifery & women’s health, 65(5), 609-
620. https://onlinelibrary.wiley.com/doi/abs/10.1111/jmwh.13104