for the following information I want to make a care plan for the MAM:
32 years old G2 P1002 with EDC May 8,2024. At 38 weeks and 07 days gestational eight who present with a report of high blood pressure while at work patient that that she is working in the ED patient denied headache vision she denies abdominal pain vagina bleeding patient report positive fetal movement.
Patient in room 4 she deliver a baby girl in 24th of April at 1016 by C-section. She had a sinus rupture of remembering cephalic position, her vital sign was 97.9 heart rate 1 oh1 respiratory 16 blood pressure 125/80, she has IV line (Patient control analogic ) of pain medication. C-section wound was clean dry range. She has a been on the abdominal region 5/10 she medication for that pain tylenoal 1000mg, and she take prenatal vitamin iron 27mg.
the care plan instruction:
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Pertinent History (including prior medical conditions, pre-pregnancy issues, issues during pregnancy (including high-risk conditions), and any issues during labor & delivery |
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ASSESSMENT (Recognizing Cues) – What did you actually see, hear, observe, assess, and any data (vital signs, lab values, etc.) This is your data to help you diagnose. |
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Recognizing/Noticing Cues – Abnormal (add lines if needed) |
Normal Assessment Items |
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DIAGNOSIS (Analyzing Cues) & Hypothesis (use data from Assessment and Pertinent History) – what could be going on with your patient? |
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Potential Conditions and what is it related to (minimum of 3 different ones) (i.e. Risk for infection related to c-section) |
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WHAT IS YOUR PRIMARY DIAGNOSIS/PROBLEM? (your data and hypothesis should be your evidence on why this is your nursing diagnosis and the rest of your care plan is based on THIS diagnosis) |
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OUTCOME/GOAL & PLANNING – needs to be SMART (specific, measurable, attainable, realistic and timed) – Choose one condition to focus on – goal should be attainable during your clinical shift – needs to be patient focused and not nurse focused (Patient will walk three times around the unit during my shift) |
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Patient will: |
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Potential Interventions (minimum of 5) add lines if needed |
Rationale |
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IMPLEMENTATION (taking action) Interventions Implemented – what did you actually do – include all interventions you performed that are listed in previous step |
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EVALUATION – Did your patient meet the Expected Outcome SMART goal you set? (met, partially met, did not meet) |
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Are there any additional parameters to monitor? |
