Tulsa Community College NUR 2423 Nursing Care of Childbearing Families Demographic Data Collection Students Name: _______________________________________________

Date: Assigned to: Mother: _____ Infant: ______ EDB: ______ Del. Date: _______ Del. Time:
Route of delivery: Vag ___ Primary C-Sec.___ Repeat C-Sec. ___ Gestation: wks ______ & days ______

Mothers Age: _____ Race: ___________ Religion :__________________ Marital Status: Gravida: _____ Para: _____ GTPAL: __________________ Blood Type: _______ EBL _______ Rubella Status: ____ GBS status: ____ Hct : pre-delivery _____post_____ Hbc: pre______post ____ Bag of waters: Assisted ____ Spontaneous Rupture ___ # of hours ruptured_____ Color: __________ Allergies: ___________________________________ Diet: Medications Taken at Home: _______ ______ ______ Eriksons Developmental Level Expected: Behavioral Evidence of Actual Level: ______ ______ ______ Infants Gender _______ APGARS: 1 min _____ 5 min _____ Blood Type ______ Coombs Weight ___ lb ____oz_____gm Length ______in ______ cm Feeding Method Frequency of feeding occurring q ______ hrs ____________

Cultural/Spiritual Traditions for new mom/new baby:

Amount taken or time at breast/feeding _____________

Eriksons Developmental Level Expected of Newborn: _______________________________________ Behavioral Evidence Expected of Newborn:________________________________________________ ____________________________________________________________________________________ Vital Sign Range Mother Previous Day Temperature Pulse Respirations Blood Pressure Pain Rating Infant Day of care Previous day Day of care

XXXXXXXXXX

XXXXXXXXXXX

Describe the mothers delivery and/ other surgical procedure(s) to mother and any surgical procedures performed on infant. Include information about labor progress: when labor began, when admitted to hospital, complications, length of stages, length of pushing. Also include pain mangemen: What, when, effectiveness. If cesarean, give reasons for that delivery route, events leading to cesarean if not planned. If any surgical procedures performed on infant, describe what, why and how. Use back of page.
(rev) 6/29/05 demographic data collection Childbearing 2005-2006

TCC Nursing Program Health Assessment/Functional Patterns Instructions: In each pattern include clients strengths, limitations, and pertinent factors influencing health. Highlight abnormal data. Health Perception Management Pattern Parents

Activity-Exercise Pattern Mother Infant

Elimination Pattern Mother Infant

Nutritional-Metabolic Pattern Complete for both clients. Mother

+Babys weight *Type of feeding Caloric needs per day Needs feedings of ________ oz q _________ hours Taking bottle feedings of ______ oz q _______ hours Or Breastfeeding for _______ min q _______ hours

Infant

*Pre-pregnant weight _________ Height *Weight at delivery *Weight gain during pregnancy

Show specific times and lengths or amounts of feedings. Show indications that newborn is or is not receiving sufficient feedings.

Cognitive Perceptual Pattern Mother Infant

Sleep-Rest Pattern Mother Infant

Sexual Reproductive Pattern Mother Infant

Coping Stress Tolerance Pattern Mother Infant

Self Perception Pattern Parents

Role Relationship Pattern Parents

Value-Belief Pattern Parents

6/24/03 health assessment/functional patterns Childbearing 2005-2006

IV Fluids and Medications P.O., Sub-Q, IM, IV, Tube, Nasal, Inhalant, Skin Patch, Topical, Rectal, Vaginal, Eye, Ear Med/Route, Frequency, Dosage Prescribed (Routine & PRN) Frequency & Dosage Taken Reason Prescribed for THIS Client Clients Response To Medication (if seen)

12/11/02 iv fluids/medications Childbearing 2005-2006

Nursing Diagnosis Sheet

Priority #

Key Problem Nursing Diagnosis (problem/etiology)

I dont know how this fits with the problems???

Priority #

Key Problem Nursing Diagnosis (problem/etiology)

Supporting Data:

Supporting Data:

Reason For Needing Health Care (Medical Diagnosis/Surgical Procedure)

Priority Assessments:

Priority #

Priority #

Priority #

Key Problem Nursing Diagnosis (problem/etiology)

Key Problem Nursing Diagnosis (problem/etiology)

Key Problem Nursing Diagnosis (problem/ etiology)

Supporting Data:

Supporting Data:

Supporting Data:

6/9/05 nursing diagnosis sheet Childbearing 2005-2006

Nursing Care Plan Student: ___Amanda Simpson_____________________ Mother: ______X_______________ Infant: _____________________ Nursing Diagnosis: Impaired Parenting related to maternal child interaction secondary to history of drug use.________________ Goal: _Initiate appropriate measures to develop a safe, nurturing environment.______________________ Specific Outcomes: (AEB Behaviors to Measure Goal Achievement) 1. Patient will hold infant. 2. Patient will identify community support group 3. Patient will state feeling of being a mother (positive/negative) 4. Patient will be negative for postpartum blues via depression scale. 5. Patient will verbalize signs/symptoms of blues.______________________ ________________________________________________________________________________________________________________________ Nursing Intervention 1. Place newborn in arms of mother Scientific Rationale and Source 1. Upon entering the room the newborn was in the crib and mother was on cell phone Implementation (I) and Evaluation (E) of Clients Response to Intervention 1. I: Placed newborn in patients arms and advised her that contact with the newborn is important to build a trusting relationship E. Patient sat on bed, relaxed and embraced the child. 2. I: Asked patient when the last time she used illicit drugs. E: Patient stated that the last time she had participated in drug use was March. 3.I: Asked the patient questions regarding family support systems and community support systems E: Patient insisted that she did not need any help with the new baby

2. Asked open ended questions about current drug use

2. Patient has a history of drug abuse (Methamphetamines)

3. Assessed the patients support system

3. Patient support system consists of her mother. The father of the child is unknown

Nursing Intervention 4. Assessed patients attitudes towards being a new mother

Scientific Rationale and Source 4. Patient had erratic behavior, affect changed constantly. She was not able to describe how it felt to her to be a mother. She avoided answering questions. 5. Patient showed no enthusiasm towards being a mother, no negative or inappropriate words about dissatisfaction with newborn

5. Assessed Patient for postpartum depression using guide in textbook

6. Taught patient common signs/symptoms of postpartum depression

6. Patient was unwilling to listen to any information she stated that the information had already been provided

Implementation and Evaluation of Clients Response to Intervention 4.I: Observed the patient for common signs of maternal-child bonding. E: Mother held newborn after being prompted by myself but was on the phone texting while holding baby 5.I: reviewed my previous assessment data and cues from patient E: Patient is at risk for for postpartum blues, my interpretation is that she has not fully grasped the responsibility that comes with caring for aa newborn 6. I: E:Patient was unwilling to listen to any information she stated that the information had already been provided

Nursing Intervention

Scientific Rationale and Source

Implementation and Evaluation of Clients Response to Intervention

Evaluation of Goal Achievement: (Met, Not Met, Partially Met); and Specific Outcomes (AEB Behaviors to Measure Goal Achievement): 1. Patient will hold infant. Patient held infant 2. Patient will identify community support group Patient states that she not in need of any help 3. Patient will state feeling of being a mother (positive/negative) 4. Patient will be negative for postpartum blues via depression scale. 5. Patient will verbalize signs/symptoms of blues Patient was unwilling to accept any new information. Patient was very distant towards me and answered only minimal open ended questions. Was unable to complete the plan of care due to the patient refusal.

6/24/03 nursing care plan Childbearing 2005-2006

TCC Nursing Program NUR 2423 Nursing Care of Childbearing Families Self Evaluation Form New Terms Definition

My learning goals are:

Achieved

Not Achieved

Strengths Knowledge: Knowledge:

Challenges

Skills:

Skills:

Attitudes:

Attitudes:

(rev) 10/28/12 nursing plan of care/evaluation criteria Childbearing 2011-2012

TCC Nursing Program NUR 2423 Nursing Care of Childbearing Families Nursing Plan of Care and Evaluation Criteria Points Deducted I. ASSESSMENT (35%) _______ 1. Collects and documents data relevant to bio/psycho/social/spiritual health of clients _______ 2. Compares assessment data to norms for assigned client population _______ 3. Documents assessment data appropriately in agency record _______ 4. Demonstrates appropriate knowledge, use of medical terms, abbreviations, symbols ________5. Identifies need for client education _______ 6. Identifies indications for and effects of prescribed medications _______ 7. Determines appropriate client problem and prioritizes II. NURSING DIAGNOSIS (10%) _______ 1. Supports nursing diagnosis with assessment data related to anatomy and physiology. _______ 2. Supports nursing diagnosis with client specific assessment data III. PLANNING (20%) _______ 1. Utilizes standards of nursing care to reflect nursing interventions that are realistic and relevant _______ 2. Identifies scientific rationale for each nursing intervention _______ 3. References scientific rationale for each nursing intervention _______ 4. Interventions planned to provide client/family education IV. IMPLEMENTATION OF INTERVENTIONS (15%) _______ 1. Implements and/or modifies written plan of care as appropriate for clients condition _______ 2. Utilizes other health care providers to promote clients health status, (if needed) _______ 3. Provides appropriate information to meet educational needs of client V. EVALUATION (20%) _______ 1. Develops appropriate client-centered outcome (goal) in specific, measurable terms _______ 2. Evaluates client response to planned nursing interventions _______ 3. Evaluates attainment of client outcome (goal) _______ 4. Explains evaluation of goal _______Total points deducted Student scored ___________ of 100 possible points Deductions: 0. Meets expectations, work legible, correct terminology wording & spelling 1. Needs improvement with legibility, terminology, wording or spelling 2. Work good, needs more specific data 3. Work good, but incomplete 4. Needs improvement in application of nursing process 5. Unsatisfactory Instructor___________________________________________________________ Date ______________________ NOTE: Students making below 76 need a faculty consultation prior to submitting next care plan. (rev) 10/28/12 nursing plan of care/evaluation criteria Childbearing 2011-2012