Postpartum Nursing Diagnosis and Nursing Care Plans

Postpartum Nursing Care Plans Diagnosis and Interventions

Postpartum Care NCLEX Review and Nursing Care Plans

As the postpartum period progresses, the woman will realize the most significant difference in herself: she is now a mother. Other changes will begin to occur as a result of this adjustment, and the mother must be prepared to deal with these life changes.

1. Psychological Changes

Within the first 24 hours after giving birth, the changes in the mother’s body, particularly in the psychological aspect, are critical. If not provided the proper attention and care, these changes may have a long-term effect on the mother.

In the postpartum period, the mother gradually accepts her maternal role following these three phases:

A. Taking In Phase

  • 1 to 2 days following delivery, the taking-in phase begins.
  • Because the mother is passive for two to three days, this is a time of reflection for her.
  • The mother becomes reliant on her healthcare provider or support person in decision-making and performing daily activities during this phase.
  • This reliance is primarily caused by physical pain from hemorrhoids or post-partum pains, the uncertainty of how she would properly care for the newborn, and the extreme exhaustion experienced after childbirth.
  • This phase is a perfect time for the mother to recover her strength and concentrate on her new role.
  • At this phase, It will be a great help for the mother’s adjustment if someone will encourage her to talk about her labor and birth experiences and how she will incorporate those experiences into her new life.

B. Taking Hold Phase

  • This phase starts 2 to 4 days following the delivery.
  • In this phase, the mother tries to act on her own and make a decision without the need to rely on others.
  • The mother begins to actively take care of the newborn instead of herself.
  • This is the perfect time to teach the mother how to properly take care of the newborn and let the mother do it afterward.
  • The mother is still in need of motivation and support in this phase because she might still feel the lack of knowledge about taking care of her child.
  • In this phase, Allow the mother to gently settle into her new role while she is still in the healthcare facility, as making decisions concerning the wellbeing of the newborn is a tough part of parenthood.

C. Letting Go Phase

  • During the letting go phase, the woman embraces her new role as a mother.
  • Postpartum depression usually appears on this phase.
  • For a smooth transition to this phase, the relationship must be re-adjusted.

2. Physiological Changes

After the delivery of the baby, several body systems are changed, and these changes may or may not be observed by the mother early in the postpartum period. There will be several major changes in the reproductive system, hormones, urinary system, and circulatory system.

3. Postpartum Care

The newborn is not the only one who requires attention after the difficult process of childbirth. It is also crucial to ensure that the mother is in good health, as the early postpartum period is critical for both the mother and the baby.

A. Care within the First 24 Hours

The following nursing care is provided after childbirth during the first 24 hours:

  • Assessment of the mother’s general appearance, pregnancy history, labor, and birth history.
  • Gathering of the infant’s data to help with the care of the newborn.
  • Assessment of any laboratory results of the mother to be sure that she is recuperating well and determine if there are any procedures that are needed to be done.
  • Assessment for signs of mastitis and palpation of fundal height and location.
  • Assessment of the uterus and applying a gentle massage if the uterus is not firm.

B. Care in Preparation for Discharge

Before being discharged, the mother must be properly educated on how to care for her newborn and herself at home.

  • Assess the mother’s ability to listen and absorb new information.
  • For the first three weeks after giving birth, instruct the mother to avoid carrying heavy objects.
  • Advise the mother to set aside some time each day to rest while the baby sleeps.
  • Make sure the woman understands that she will need to return to the healthcare facility for an assessment in 4 to 6 weeks.
  • Determine that the woman and her family completely understood the discharge instructions. Review the instructions and ask if they have any questions.

C. Care after Discharge

Discharge from the hospital normally happens 2 to 3 days after the baby is born.

  • Following the discharge, a home visit is frequently recommended to see how the parents are doing now that they have a baby at home.
  • Examine the woman’s expectations and perceptions, including whether she plans to return to work outside the home and whether she has already made arrangements for her newborn’s care while she is gone.
  • Conduct a family assessment to see if other family members are adjusting well to having a newborn in the house.

Postpartum Nursing Diagnosis

Postpartum Care Nursing Care Plan 1

Impaired Parenting

Nursing Diagnosis: Impaired Parenting associated with difficulty in performing activities of daily living and stress secondary to postpartum depression as evidenced by a continuing feeling of sadness, fatigue, and extreme anxiety.

Desired Outcome: The patient will be able to verbalize her feelings and insecurities, adhere to medication regimen and lifestyle modification, and the patient will be able to keep the social circle to gain support. Thus, the patient will be able to perform activities of daily living and will be able to properly take care of the newborn.

Postpartum Nursing InterventionsRationale
Assess the patient’s psychological health before and after the delivery and determine the patient’s history of illness, hospitalization, and medication.This is done to determine if the patient needs any counseling and support groups to avoid postpartum depression.
Create a plan with the patient and explain the importance of adhering to the daily activities, including exercise and sleep routine, as well as the nutrition program.Taking care of the newborn can cause fatigue, adequate rest periods and self-care are very important this time, eating a balanced diet is also essential in maintaining health.
Encourage the patient to keep communicating with friends and family through calls and video communication.  This will serve as the patient’s support system and will allow her to express her feelings and insecurities. feelings are vital in the patient’s recovery from postpartum depression. The patient may experience extreme loneliness that may cause depression if there is no one to talk to.
Advise the patient that it is fine to take some time for herself every day, like taking a warm bath, doing moderate exercise, or doing yoga.Depression can be a result of the stress that the patient is experiencing, that’s why it is important for the patient to feel like herself again and take some break from regular baby care to avoid exhaustion.
Determine if the patient is compliant with the medicines and other interventions that the physician ordered and make sure that the patient adheres to the clinic follow-up schedule.Strict adherence to medication regimen and scheduled follow-up will greatly contribute to bringing the patient to good holistic health.

Postpartum Care Nursing Care Plan 2

Risk for Infection

Nursing Diagnosis: Risk for infection related to stasis of body fluids, an invasive procedure causing traumatized tissues, and decreased hemoglobin secondary to postpartum hemorrhage.

As a risk nursing diagnosis, Risk for Infection is not associated with any signs and symptoms since it still has not manifested in the patient and preventive measures will be done instead.

Desired Outcome: The patient will verbalize understanding of individual causative/risk factors for infection, the patient’s white blood cell count and vital signs will be within normal range and the patient’s odor will be clear of lochia.

Postpartum Nursing InterventionsRationale
Document the patient’s rate and nature of uterine involution, as well as the amount, color, and odor of lochial discharge.Infection of the uterus causes involution to be delayed and the lochia to flow more slowly.
Observe and ask the patient to report any signs of fever such as chills and elevated body temperature, body pain, inability to eat, pelvic pain, and uterine tenderness.If left untreated, these symptoms indicate systemic involvement, which could result in bacteremia, shock, or even death.
Assess the patient for edema, erythema, separation of wound borders, and purulent drainage at the episiotomy site and abdominal wound for caesarian section.This implies a localized infection that requires keen attention to avoid systemic complications.  Check for additional infections such as a urinary tract infection, mastitis, and lung infection. Advise the patient to report symptoms such as frequent or painful urination and murky or odoriferous urine,  if there is swelling, erythema, or pain on the breast, and if there is productive cough, purulent sputum, and fever.Differential diagnosis is essential for successful treatment.
Demonstrate to the patient and allow the patient to perform a return demonstration on proper hand-washing and self-care procedures. Explain the proper way of disposing and handling contaminated materials such as dressings, peripads, and soiled linens.This technique prevents the spread of infectious and harmful organisms.
Determine if there is a deviation in the patient’s WBC, hemoglobin, and hematocrit levels.  Infection is indicated by an increase in white blood cell count. Anemia is commonly associated with infection, and it slows wound healing and weakens the immune system.  
Assess if the patient’s lochia has an odiferous odor or purulent wound discharge, obtain a gram’s stain or culture and sensitivity test.Gram stain determines the type of infection, whilst cultures and sensitivities determine the pathogen and can help determine which antibiotic is most effective against it.

Postpartum Care Nursing Care Plan 3

Risk for Pain

Nursing Diagnosis: Risk for pain related to tissue damage secondary to postpartum hemorrhage. As a risk nursing diagnosis, Risk for Pain is not associated with any signs and symptoms since it still has not manifested in the patient and preventive measures will be done instead.

Desired Outcome: The patient will determine alternative pain relief options and verbalize understanding of the best methods for pain relief,  will show the application of relaxation strategies as well as diversional activities as indicated, And the patient will express total relief from pain and discomfort.

Postpartum Nursing InterventionsRationale
Assess the patient regarding the psychological factors that contribute to pain and discomfort. Ask the patient to express feelings of fear and what causes fear.The patient’s fear and anxiety are common in emergency situations, and they can heighten the feeling of pain and discomfort.  
Assess the pain by asking the patient to verbalize the type, location, characteristic, severity, and length of the pain and use a 0-10 pain scale. 0 as no pain and 10 as the highest rate for pain.This method will assist in differential diagnosis and help in determining the best treatment option for the patient.
Encourage the patient to use alternative relaxation techniques and diversional activities such as watching TV and listening to music, teach the patient how to perform deep breathing exercises.These methods will help to support the client in exploring other possible pain management options.
Apply necessary additional comfort measures to episiotomy extension and teach the patient how to utilize comfort measures such as applying an ice pack in the perineum, doing a sitz bath, or using a warming lamp.Heat stimulates vasodilation, which aids in hematoma resorption, whereas ice reduces edema and diminishes hematoma and pain sensation.
Administer pain medications to the patient and teach the patient how to take medications as directed.Pain medications reduce pain and anxiety easily and aid in relaxing.  

Postpartum Care Nursing Care Plan 4

Anxiety

Nursing Diagnosis: Anxiety related to the maturational or situational crisis, interpersonal transmission, the threat of health status alteration, drug therapy, and unaddressed social needs secondary to postpartum hemorrhage as evidenced by increased anxiety, uncertainty, and a sense of helplessness, concerns expressed as a result of changes in life events, restlessness, and inability to pay attention.

Desired Outcome:The patient will be able to express feelings and concerns by speaking about them, will be able to learn different methods on how to deal with and express anxiety in a healthy way, will appear more relaxed, and will be able to sleep properly and the patient will report a decreased experience of anxiety attacks.

Postpartum Nursing InterventionsRationale
Encourage the patient and family to recognize symptoms of anxiety, such as restlessness, nervous feeling, a sense of impending doom, tachycardia, sweating, and trembling.The ability to recognize anxiety aids in clarifying information, rectifying misconceptions, and gaining perspective, all of which helps in the problem-solving process.  
Always maintain a calm, compassionate, and helpful approach when staying with the patient.  To aid in the maintenance of emotional control in the response to shifting physiological status. Helps in minimizing the transmission of interpersonal feelings.
Provide accurate information to the patient, answer the patient’s questions accurately and discuss the treatment plan and the success of treatments options.  Giving factual information can help to reduce anxiety and distinguish what is based on reality.  
Assist the patient in the development of abilities, for example, recognizing negative thoughts and saying “Stop” to replace them with a positive thought.To get rid of negative thoughts and promote mental health.
Help the patient in analyzing the body’s reaction to a postpartum hemorrhage, Ask the patient to report symptoms such as restlessness, irritability, tachypnea, tachycardia and hypotension.Physiologic responses can cause changes in vital signs, but psychological responses can also aggravate them.
Assess the patient’s psychological reaction to the postpartum hemorrhage and their assessment of the events that have occurred.This can help in the development of a treatment strategy. The patient’s perspective of the event may be twisted, thus making her feel more anxious.  

Postpartum Care Nursing Care Plan 5

Ineffective Tissue Perfusion

Nursing Diagnosis: Ineffective Tissue Perfusion related to venous blood flow interruption secondary to postpartum thrombophlebitis as evidenced by pallor or cyanosis, prolonged capillary refill time, non-palpable peripheral pulses, edema of the affected extremity, erythema, and pain.

Nursing Stat Facts
Nursing Stat Facts

Desired Outcome:  The patient will demonstrate the desirable circulation of affected extremity as evidenced by equally palpable peripheral pulses, normal capillary refill time, reduced swelling, and erythema, and the patient will verbalize absence of pain.

Postpartum Nursing InterventionsRationale
Assess the patient for a positive Homans’ sign, note the presence of calf pain at dorsiflexion of the foot). and track capillary refill time.DVT might cause a delay in capillary refilling. The presence of a positive Homans’ sign isn’t always a reliable predictor of DVT.  
Assess the patient’s extremities circulation, asymmetry, sensory, and motor function; observe edema from the groin to the foot; measure and record calf/thigh circumference in both legs as needed. Report proximal inflammatory progression and traveling pain.    The symptoms of superficial thrombophlebitis and DVT can be distinguished using the symptoms. Surface involvement is characterized by localized edema, redness, warmth, and discomfort. DVT is characterized by pallor and coldness of the extremities. Calf vein DVT is usually characterized by the absence of edema; mild to moderate edema indicates femoral vein involvement, and severe edema indicates ileofemoral vein thrombosis.  Assess the patient’s lung sounds and note if there is a presence of crackles or friction rub Investigate any complaints of chest pain or anxiety.    Pulmonary emboli, especially in DVT, are characterized by pulmonary congestion, sudden intense substernal chest pain, anxiety, shortness of breath, high heart rate, and hemoptysis.  
Ensure that the patient is staying in bed with the feet and lower legs elevated above the heart during the acute phase.Reduces the risk of thrombus dislodging and emboli formation. Increases venous return by rapidly emptying superficial and tibial veins and keeping veins compressed.
Assist the patient in performing active or passive ROM and Assist the patient with the progressive return of ambulation as directed.    Increases venous return reduces venous stasis, and keeps muscle strength.
Instruct the patient to apply warm, moist compresses or a heating pad to the affected extremity as directed.  Improves venous return, improves circulation, and minimizes edema.  

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines, policies, and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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