Maternal Care Plan for C- Section Delivery
Nurse care plan for postpartum patient c-section delivery
Care plan expectations:
No less than three no more than five diagnosis.
Each diagnosis needs two measurable and obtainable goals - One long term and one short term goal. Each goal must be measurable and obtainable.
Each Goal needs at least three interventions. As a nurse how would you attain these goals you have set.
Next, you have your nursing rationales why did you do the interventions. Where is the evidence to support what you are doing? This is where you will reference using APA format.
Cite your sources and provide reference page. At least one source (textbook).
Finally, evaluation you will say whether the goal was met or not met. If not met how/what could you do differently to make an obtainable goal.
APA format is easily located from Googling “Purdue Owl” or simply typing in your search engine
Ancilla College Care Plan Rubric
NAME________________________________ Date of Care____________________________
Score |
10 |
5 |
3 |
1 |
0 |
Assessment |
All areas complete, specific and accurate or write N/A.
|
1-2 sections incomplete, information specific and accurate or write N/A |
3-4 sections incomplete information is generalized and accurate or N/A |
Poor use of medical or nursing terminology, misspelling, incomplete sentences |
Incomplete assessment or inaccurate data |
Diagnosis |
NANDA approved, highest priority, individualized and in PES format. |
NANDA approved, highest priority, low individualization PES format |
NANDA approved, lower priority, low individualization PES format |
NANDA approved, low priority, not individualized PES format |
Not NANDA approved, No priority, No individualization |
Planning NIC/NOC |
Individualized, attainable goal with stated time frame, interventions appropriate for diagnosis |
Individualized, with attainable goal, 3 or more interventions appropriate for diagnosis |
Individualized, with attainable goal, interventions appropriate for diagnosis, less than 3 appropriate interventions |
Generalized with attainable goal and time frame. Interventions generalized |
No goal provided, not appropriate for diagnosis, incomplete |
Evaluation |
Every intervention reviewed & evaluated. Revisions noted when appropriate |
Every intervention reviewed; no revisions provided when appropriate |
Interventions were not reviewed or revisions listed are not priority focused for patient. |
Limited review no revisions listed. |
Evaluations do not relate to interventions |
Medications |
All medication cards are completed as the example. |
Medication cards complete but not relevant to specific patient. |
Not relevant to patient or 1-2 parts of the med card is missing |
3-4 parts of the med card are missing |
>4 parts missing |
Score |
|
|
|
|
|
- Total Score________ Total Possible 50 points
Maternal Care Plan
Name
Course Instructor
Date
Diagnosis
PES Format Outcome/Goals
Include Time FrameInterventions
Individualized/SpecificRationale
Include page numbersEvaluation
Updates/Desired OutcomeNursing Diagnosis: Anxiety
Related to: Situational crisis, perceived threat to self and the infant and interpersonal transmission.
As evidenced by: Increased tension, distress, restlessness, and sympathetic stimulation.
Diagnosis
Nursing Diagnosis: Powerlessness
Related to: A lifestyle of helplessness and interpersonal interaction.
As evidenced by: Passivity and lack of participation and involvement in making decisions on their care and treatment.
Diagnosis
Nursing Diagnosis: Sensory/ Perceptual alterations.
Related to: Excessive noise level, psychological stress, and multiple environmental stimuli.
STG: Patient is able to discuss feelings about caesarian birth and share her safety concerns on the infant and herself within hours after nursing intervention.
LTG: Patient is relaxed and comfortable 2-3 days into the nursing treatment/intervention.
Outcome/ Goals
STG: Patient becomes vocal about her fears and feelings and starts to express her feelings and desires within hours of the nursing interventions.
LTG: Patient shows concerns on her treatment and participates in decision making.
Outcome/Goals
STG: Patient exhibits relaxation and shares her understanding for increased level of activity.
LTG: The patient maintains focus and is able to tune out extraneous distractions.STG#1: It is essential to assess psychological perception and response to the caesarian birth and determine availability of support systems.
STG#2: ...
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