Posted: August 13th, 2015

Care plan.

THE CARE PLAN DOCUMENTATION
The format of the care plan includes woman’s demographics, parity, the mothers’ history of the labor, signs of true labor, and duration of her labor i.e. from the onset to the 3rd stage. The care plan documentation should include the follows aspects:
A. Patient profile
1) Patient’s demographics
2) Parity
3) Duration of the labor (Onset to 3rd stage)
4) Staging of the labor/delivery
B. 1st stage –
a. To include the physiological changes occurring during labor
b. Also to elaborate on the following:
i. Assessment
ii. Interventions
iii. Rationale
iv. Outcome
C. 2nd stage –
a. To include the mechanism of labor
b. Also to elaborate on the following:
i. Assessment
ii. Interventions
iii. Rationale
iv. Outcome
D. 3rd stage – Delivery of the placenta
All the interventions carried out for your patient should include medications as well as comfort measures employed during the progress of labor/delivery to promote comfort and the relieve of pain.
E. The baby
a. Discuss the examination of the newborn to exclude any abnormalities.
b. Describe the immediate newborn care after vaginal or caesarean delivery followed by the daily newborn care
F. The lying-in or postpartum period
a. List and discuss any complications that occurred with the mother during the post-partum period.
G. Discuss the discharge instructions for your patient.

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