Oakton Community College s6

Student______Date______

Post Partum Care Plan

Clients Initials______Age______Martial Status ______Religion ______Culture ______

Prenatal Classes_____ Support Person ______Pre-pregnancy Wt ______Present Wt ______

EDC______Gravida______Para_____ LC______Gestation by dates______

Type of Delivery ______Date of Birth ______Time______Sex of baby______

Weight ______Length ______APGARS ______Baby Blood Type ______

Allergies ______

History: List any significant history of current pregnancy either prior to or during pregnancy (prenatal): Current Medications, illnesses, previous surgeries, exposure to communicable diseases, problems or concerns, amount of weight gain.

Describe past obstetrical history in terms of year of birth, gestation, length of labor, and any problems during pregnancy or post partum

Prenatal Labs : Blood Type & Rh of mother______Rubella Titer ______Hepatitis B ______Describe history of current delivery (onset of contractions, rupture of membranes, induction or augmentation of labor, anesthesia - IV/IM meds, local, epidural, paracervical block, pudendal, -how long in labor, pushing, after birth, etc.)

Medications: Name, Dose, Route, Frequency, Action, Side Effects

Physical Assessment

Describe findings for Activity/Exercise: Vital Signs, Fundus, Episiotomy, Pad saturation, Lochia, Edema, Homan’s Sign, and Lung sounds Include any interventions such as ice pack to perineum. Lab findings – Hgb and Hct, and work-up if Rh negative.

Describe findings for Nutrition/Metabolism: Skin turgor, mucus membranes, diet, IV fluids, current appetite, formula feeding or breast feeding. Include any interventions you performed. Describe findings for Elimination: Bowel sounds, hemorrhoids, perineal swelling/laceration, amount voided since delivery, hours since delivery, frequency of urination, catheterized during hospitalization, history of UTI. Include any interventions you performed.

Describe findings for Cognitive/Perceptual: pain in terms of episiotomy, contraction of uterus, breast, etc. Headaches, numbness, tingling, LOC, cranial nerve assessment, coordination, sensation, activity Behavior in terms of calm, cooperative, anxious. Include any interventions you performed.

Health Management/Health Perception: Describe findings of general health perception, changes in her life to protect her baby, and important measures doing for family safety. Self Perception/Self Concept: Identify and describe findings for Erickson’s Stage of Development, education, occupation, and indications of creativity and problem solving ability.

Coping and Stress Tolerance: Describe reaction to pregnancy and birth of baby, activities that have worked in the past to help cope and relieve stress, the most difficult change anticipated with the arrival of the new baby, anticipated sleep patterns changes with the new baby, activities done for relaxation, and plans for rest when discharged.

Role/Relationship: Describe family members, primary care giver, shopping, cooking, laundry. Pets. Perception of changes to family relationship

Values/Beliefs: Describe client’s primary language. Cultural traditions want to pass on to child. Religious traditions want child to continue. Describe Client’s Response to infant:

Describe Clients Knowledge of: breast care, involution, elimination, Infant Care, Medications Include goals