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OB Concept Map

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by

Samya Senan

on 15 December 2013

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Transcript of OB Concept Map

Perinatal Concept Map
M o t h e r
B a b y
22 y/o
G2P1
LMP: 1/8/13
EDD: 10/15/2013
NSD
9 hours postpartum
Superficial vaginal laceration
Contemplation stage
"Taking-in" phase
AGA baby girl
Born: 10/16/13
GA: 40 weeks
Delivered via NSD
BW: 3140g (6lbs.,15oz.)
APGAR: 9 and 9
Breastfed
Umbilical hernia
Physiological
Risk for altered homeostasis r/t potential risk of hemorrhage secondary to possible uterine atony (First 24h PP)

Risk for impaired perineal integrity r/t perineal trauma secondary to childbirth

Risk for altered healing process, possible pain & infection r/t perineal laceration secondary to childbirth

Pain r/t superficial vaginal mucosa laceration

d i a g n o s e s
Nursing Interventions
Establishing independent thermoregulation r/t physiological adaptation to extrauterine life

Establishing of cardiopulmonary functions r/t physiological adaptation to extrauterine life

Establishing GI & GU functions r/t physiological adaptation to extrauterine life secondary to umbilical hernia.

Psychological
Assess VS
Massage fundus
Provide nonpharmacological comfort measures
Notify HCP if excess bleeding occurs
Assess pain: COLDSPA
Give meds as ordered
(Oxytocin, Methergine, Hemabate)
Provide analgesics as ordered
Monitor VS
Notify HCP if signs of infection are present
Instruct in peri care, incisional care, and breast care
Keep perineum clean/dry
Place an absorbant pad, and change when damp
Cleanse perineum after each voiding/defacation
Anxiety r/t impending discharge from hospital as evidenced by verbal expression of fears on child’s herniated umbilicus.

Disturbed body image r/t physiological changes from pregnancy.

Readiness for enhanced coping as evidenced by seeking social support and knowledge of new strategies
d i a g n o s e s
Nursing Interventions
Be calm/reassuring with patient and family
Explain all procedures
Encourage pt & family to verbalize feelings
Acknowledge normalcy of emotional response to bodily changes
Encourage verbalization of positive/negative feelings
Demonstrate positive caring in routines
Assess pt's usual coping methods
Establish trusting relationship w/pt
Begin discussions at pt's level of comfort
Physiological
Auscultate abdomen & note bowel activity
Document GI/GU activity & report abnormal findings
Ensure proper feeding
Assess VS
Conserve heat by swaddling
Avoid situations that may promote heat loss
Assess VS
Clear airways w/bulb syringe
Auscultate heart for 1 minute
Auscultate breath sounds for 1 minute
L e a r n i n g N e e d s
Knowledge deficit r/t newborn feeding cues due to lack of experience and/or information

Knowledge deficit r/t newborn umbilical hernia

Knowledge deficit r/t prevention of complications from vaginal laceration

Teaching
&
Learning Needs

By Samya Senan
Transtheoretical Stage of Change
Pt. in Contemplation Stage
Pt. is planning to start healthy behavior w/in next 6 months

During this time, the pt. is weighing out the "pros" and "cons" of continued actions as well as change
Maternal Adaptation Phase
Phases
Taking-in
Taking-hold
Letting-go

First 24-48 hrs after birth
Behaviors:
Taking-In
Personal comfort and physical changes
Relives of experience
Adjusts to psychological changes
Dependent
Decreased ability to make decisions
Concentrates on physical healing
Learning Assessment
5 Rights of Teaching
Timing
Learning Needs
Maternal self-care
Knowledge deficit r/t prevention of complications from vaginal laceration

Infant Feeding Method
Knowledge deficit r/t newborn feeding cues due to lack of experience and/or information
Infant Care
Knowledge deficit r/t newborn umbilical hernia
Outcome Assessment
References
Chapman, L., & Durham, R.F. (2010). Maternal-newborn nursing. Philadelphia, PA: F.A. Davis Company.
Swearingen, P.L. (2008). All-in-one care planning resource. (2nd ed.). St Louis, Missouri: Mosby Elsevier.
Context
Goal
Content
Method
Signs of slight perineal discomfort
Teaching postponed until free from pain
Room was quiet and comfortable for the pt.
2 visitors room (best friend and sister-in-law)

Objectives realistic and valued
Pt motivated to learn AEB asking questions
Family and friends included in plan
Appropriate/relevant
Content presented at learner’s level
New info + reinforcement of previous info

Teaching strategies fit client’s learning ability
Patient demonstrated understanding of teaching by verbalization

Monitor s/s of infection
Promote aseptic techniques
Assess knowledge/previous experience
Inform about early feeding cues
Reassure pt. defect not harmful
Inform pt. about strapping protrusion down (not effective)
Effective teaching?
Pt. identifies perceived learning needs

Pt. verbalizes understanding of teaching for infant care and self-care (umbilical hernia & peri-care)

Pt. demonstrates desired skill by identifying early feeding cues

d i a g n o s e s
Nursing Interventions
Goals
Baby will achieve independent thermoregulation
Baby will achieve stable cardiopulmonary function
Promote & ensure proper GU/GI activity
Pt. demonstrates positive coping mechanisms
Pt. demonstrates enhanced body image and self-esteem
Goals
Pt shows no signs of hemorrhage
Pt. properly promotes self healing
Pt. is free of infection
Pt. is relieved of pain or expresses decreased pain
Goals
1
5
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