NRG5000 Theoretical Foundations of Nursing Dr. Lisa Capps, Faculty Guidelines for Nursing Process: Maternal Nursing Patient Care Plan Nursing Diagnosis: Nursing diagnosis consists of the diagnostic label, “related to” and the “as evidence by” components. A “Risk for…” diagnosis does not have “as evidence by”. Diagnostic label: Is selected from the NANDA International Diagnosis. “related to” the condition or etiology of the problem the patient is experiencing. “as evidenced by” assessment data that supports diagnosis Assessment as evident by (AEB), or data collection relative to the nursing diagnosis Outcome (objective, expected or desired outcomes or evaluation parameters Interventions/ Implementations/ SHOULD HAVE RATIONALE FOR EACH INTERVENTION Evaluation (Each OUTCOME needs an evaluation statement) Assessment supports the nursing diagnosis above. The assessment should reflect the “defining characteristics” that are expected to be present for that diagnosis to be appropriately utilized. Types of data: subjective & objective Sources of data Nursing health history Physical examination Diagnostic data The OB care plan will focus on short term outcomes. “What do you/your patient want to achieve today? …at next assessment?” Should be acceptable by the patient and the nurse, realistic, specific and measurable Stated realistic behavioral terms that can be observed, measured and relevant to the identified nursing diagnosis. Intervention – The planned nursing actions that are likely to achieve the desired outcomes Interventions should reflect on going assessment and activities that will assist in achieving the goal/outcomes. Interventions should reflect independent nursing practice as well as collaborative practice. Interventions should reflect the needs of this specific patient not a generic listing of possible interventions. Interventions should include specifics like schedules, food choices, frequency, etc…. Rationales- reasoning behind your choosing the intervention; scientific explanation and/or underlying reason for which the intervention was chosen for your patient Focuses on change and compares the changes with the outcomes Essentially this is a reassessment of the patient and the responses as to the interventions implemented. Compare actual patient behaviors with expected behaviors. Consider the effectiveness of the nursing intervention, time elements. Give reasons why or why not each outcome has been met. If the outcome is “unmet” what is your plan to meet outcome in the future or does the outcome need to be revised? Nursing and the Care of Childbearing Families Student Name: Gladys Mireku Date of Care: 10/2/2022 Focus of Care Plan: (highlight one Labor/Birth Postpartum Newborn Identifying information: Complete information section for MOTHER on Labor Care Plan Complete information sections for MOTHER and NEWBORN on Postpartum and Newborn Care Plan MOTHER Initials: M.K Gr ...

1. NRG5000 Theoretical Foundations of Nursing
Dr. Lisa Capps, Faculty
Guidelines for Nursing Process: Maternal Nursing Patient Care
Plan
Nursing Diagnosis:
Nursing diagnosis consists of the diagnostic label, “related to”
and the “as evidence by” components.
A “Risk for…” diagnosis does not have “as evidence by”.
Diagnostic label: Is selected from the NANDA International
Diagnosis.
“related to” the condition or etiology of the problem the patient
is experiencing.
“as evidenced by” assessment data that supports diagnosis
Assessment as evident by (AEB), or data collection relative to
the nursing diagnosis
Outcome (objective, expected or desired outcomes or evaluation
parameters
Interventions/
Implementations/
SHOULD HAVE RATIONALE FOR EACH INTERVENTION
Evaluation
(Each OUTCOME needs an evaluation statement)
Assessment supports the nursing diagnosis above. The
assessment should reflect the “defining characteristics” that are
expected to be present for that diagnosis to be appropriately
utilized.

2. Types of data: subjective & objective
Sources of data
Nursing health history
Physical examination
Diagnostic data
The OB care plan will focus on short term outcomes.
“What do you/your patient want to achieve today? …at next
assessment?”
Should be acceptable by the patient and the nurse, realistic,
specific and measurable
Stated realistic behavioral terms that can be observed, measured
and relevant to the identified nursing diagnosis.
Intervention –
The planned nursing actions that are likely to achieve the
desired outcomes
Interventions should reflect on going assessment and activities
that will assist in achieving the goal/outcomes.
Interventions should reflect independent nursing practice as
well as collaborative practice.
Interventions should reflect the needs of this specific patient
not a generic listing of possible interventions.
Interventions should include specifics like schedules, food
choices, frequency, etc….
Rationales- reasoning behind your choosing the intervention;
scientific explanation and/or underlying reason for which the
intervention was chosen for your patient
Focuses on change and compares the changes with the outcomes

3. Essentially this is a reassessment of the patient and the
responses as to the interventions implemented.
Compare actual patient behaviors with expected behaviors.
Consider the effectiveness of the nursing intervention, time
elements.
Give reasons why or why not each outcome has been met.
If the outcome is “unmet” what is your plan to meet outcome in
the future or does the outcome need to be revised?
Nursing and the Care of Childbearing Families
Student Name: Gladys Mireku Date of
Care: 10/2/2022
Focus of Care Plan: (highlight one Labor/Birth
Postpartum Newborn
Identifying information: Complete information section for
MOTHER on Labor Care Plan
Complete information sections for MOTHER and NEWBORN
on Postpartum and Newborn Care Plan
MOTHER Initials: M.K Gravida 1 Para 0 (4-digit Parity)
EDC: 9/27/2022 Gestational age: 41 weeks
Amniotic fluid Clear (clear or meconium in fluid) Prenatal
Group B Strep: Positive
Did mom receive antibiotics in labor: Yes
Abnormal prenatal test results:
Not Known QBL: Not yet Blood Type: A
positive Type of anesthesia used during labor and/or birth
(if applicable): Not yet Current Medications: Pitocin,

4. Dilaudid ,Misoprostol
Episiotomy or laceration (describe by type and/or degree):Not
yet
NEWBORN Initials’ Birth date: Time of birth: not yet Sex:
Female Gestational age: not yet Birth weight Not known
lbs./oz. grams
Age (in hours): Not yet APGAR scores at birth: Not yet (one
minute), Not yet (5 minutes) Method of feeding: Breast
feeding
Blood type: Not yet known Coombs: Not yet known TCB or
TBili: Not known Glucose: Not known
Additional Information:Complete information below for Labor,
Postpartum, and Newborn Care Plans
Type of birth: (circle) vaginal delivery Cesarean-
section Vaginal Birth After Cesarean (VBAC) not born yet
Is there history of any high-risk situations or complications
during previous pregnancy, labor/birth, or postpartum period?
YES : NO; None
If yes, please list:
Is there history of any complications during current pregnancy,
labor, birth, postpartum, or newborn? YES: NO:
If yes, please list:
Nursing Diagnosis: (include all 3 components): Diagnosis
Pain
R/T__________ASB_________________________
Assessment or data collection relative to the nursing diagnosis
(provide subjective and objective assessments)
(This is your assessment of your patient)
Patient Outcome (objective, expected or desired outcomes or
evaluation parameters)
INCLUDE 2 COUTCOMES

5. (S-M-A-R-T)Interventions/Implementations and Rationale
(specific nursing actions- MUST include a rationale with each
intervention)
(INCLUDE at LEAST 3 INTERVENTIONS AND
RATIONALES)Evaluation
(include whether outcome was met, partially met or unmet)
If the outcome is “unmet” what is your plan to meet outcome in
the future?
Outcome #1:Interventions and Rationales for Outcome #1:
1.)
2.)

6. 3.)
Evaluation for Outcome #1:
5
4.06.22

7. Outcome #2:Interventions and Rationales for Outcome #2:
1.)
2.)
3.)Evaluation for Outcome #2:
NRG5000 Theoretical Foundations of Nursing
Dr. Lisa Capps, Faculty
1
NUR4025 Maternal Newborn Care Plan Assignment Rubric
Student Name: _______________________________
(Select): Postpartum Labor Newborn
Description
Totals
Patient Information and Health Assessments
· Complete Patient Demographics

8. · Reproductive History
Information Related to Current Pregnancy
Information Related to Prior Pregnancies
· Newborn Information (if delivered)
· Current Medication
· Lab Work/Diagnostic Data
____/ 5
Nursing Diagnosis:
· Reflects the primary diagnosis
· Appropriate for patient scenario as well as priority level
· In acceptable NANDA format
· Includes all parts stem, R/T, AEB
____/ 2
Complete a Nursing Process Table for the primary nursing
diagnosis
Assessment:
· Appropriate for chosen diagnosis
· Includes objective & subjective historical support diagnosing
data
·
____/ 3
Patient Outcomes:
· Include at least 2 outcomes for the diagnosis
· Specific to the patient diagnosis
· Contains the following 4 criteria:
measurable, attainable, realistic, and timed
· All criteria present for patient’s expected outcome
____/2

9. (Outcome 1)
____/ 2
(Outcome 2)
I
ntervention/Implementation:
· Include at least 3 nursing interventions for each patient
outcome
· Includes interventions/ nursing actions directly relating to pt.
outcomes
· Specific in action, frequency and contain rationale
· # of interventions is appropriate to help pt./ family meet their
outcomes
____/3 (Interventions and Rationales for Outcome 1)
____/ 3
(Interventions and Rationales for Outcome 2)
Evaluation:
· Must have an evaluation statement written for
each patient outcome
· Includes all data that is listed as criteria in outcomes
· Outcomes are determined to be met, partially met, or not met
If outcome was not met/ partially met, plan of care is revised/
continued & new evaluation date/time is set
____/2
(Evaluation for Outcome 1)
____/ 2
(Evaluation for Outcome 2)

10. Total Points:
____/24