Brenda patton was admitted to labor and delivery

1 BOWIE STATE UNIVERISTY NURS 381 PRENATAL/INTRAPARTAL/POSTPARTAL/ CARE PLAN FORMAT INTRODUCTION: Provide a brief introduction of your patient to include: initial, age, blood type, PNC, GBS status, GTPAL, Gestational weeks, decelerations, membrane rupture, labor induced or augmented, Type of delivery-vaginal/cesarean. If cesarean, state reason and type of incision, Previous or intended contraceptive method, race, allergies, code status, past surgical history, reason for admission, Fetal presentation and position, Pre-pregnancy and total weight gain ASSESSMENT: 2 Integrate lab data, GYN, medical and social histories where applicable notably: Hypertension, Diabetes, heart disease, COPD, smoking, alcohol, and substance abuse etc. Note both physiological and psychosocial problems Date of Patient Care: Problems in NANDA format: Stem & Etiology. Identify ALL applicable problems in each system Vital Signs: Neurological: Cardiovascular: Respiratory: 3 GI (Assess for bowel elimination and nutrition among others) GU: Musculoskeletal: Integument ( include skin changes, episiotomy, laceration, incision, and hemorrhoid) 4 Reproductive (Include assessment of breasts, uterus, perineum, and lochia) Spiritual (Impact of spiritual belief system on maternal and or newborn care, including infant care practices, rites of passage, and choice of contraceptive method, if applicable) Sociocultural (Include socioeconomic status and awareness of Community Resources that support the Childbearing Family. Note impact of cultural belief system on expectations for maternal behavior during the postpartal period. (For example, is the mother allowed to leave the home right after the birth? If not, how long must she wait before she and the baby are allowed to leave the home?) Psychological (Include maternal-infant bonding behavior) 5 Developmental (Maternal Development, age, and impact on acceptance of parenting role and parenting behaviors) Laboratory & Diagnostic Results: If lab/diagnostic data is not available, discuss expected normal values with rationales Lab Result Normal Value Implications/rationales RPR GBS Rubella Hepatitis HIV Chlamydia . 6 Gonorrhea WBC Hemoglobin Hematocrit Platelet Other 7 Medications: Include ALL applicable meds: Antibiotics, Antiviral,