DIAGNOSIS SHORT TERM GOALS
Risk for ineffective
breastfeeding R/T lack of
experience, delayed start,
hospital routines and
polices, physical
abnormalities (specify) or
maternal anxiety,
stressor pain
Risk for ineffective tissue
perfusion r/t blood loss
secondary to childbirth
Altered Nutrition,
imbalance: less than
body requirements r/t
decreased intake,
decreased peristalsis
secondary to surgery
(C/S)
and increased metabolic
needs and lack of
choices
(BOTH)
Risk for constipation R/T
LONG TERM GOALS NURSING INTERVENTIONS
Infant will latch-on with Same 1. Assess mother’s breasts, nipples, pain level
nutritive suck and audible when breastfeeding, and satisfaction q 4-8 hrs
swallowing as evidenced 2. Assess breastfeeding dyad for proper
by appropriate # of stools positioning and latch-on each shift or prn
and voids for age with no 3.. Monitor infant’s stools and voids
supplements 4. Teach frequency, duration, assessing milk
supply, wake-up techniques, etc (all topics) and
Mom free of moderate to reinforce as needed
severe nipple pain and 5. Assist with feedings as needed or requested to
engorgement and help with positioning and latch-on
issatisfied with
breastfeeding
Fundus will remain firm & Color acyanotic, cap refill< 1.Monitor fundus, lochia, VS, color, and cap refill q
midline at appropriate 3 seconds,; vital signs __ hrs
fundal height with small- within range of admitting 2.Monitor urinary output and for bladder distention
moderate rubra lochia vital signs; Hgb ≥ 10 3. Teach patient to massage her fundus
frequently
4. Administer fluids and pitocin as ordered
5. Monitor labwork
Will consume 50-75% of Will consume ≥ 75% of 1. Assess for bowel sounds if C/S
prescribed diet without n, regular or prescribed diet 2. Provide diet as ordered
v, d without n. v. or d 3. Monitor for n, v, d
4. Progress diet as tolerated and record
percentages
5. Teach about dietary needs
6. Provide patient selection of meals if available
Will have active bowel Will have at least one soft 1. Assess for bowel sounds and passing flatus
decreased peristalsis,
limited intake and
decreased mobility
secondary to Cesarean
delivery
Risk for constipation r/t
inflammation, edema,
decreased mobility, fear
of tearing stitches or pain
secondary to vaginal
delivery
Altered or Impaired
urinary elimination r/t
dieresis, dehydration and
edema and inflammation
of urinary meatus
Caesarean delivery)
secondary to removal of
foley and decreased
muscle tone secondary to
anesthesia
Vaginal delivery
secondary to vaginal birth
Risk for fluid volume
deficit r/t diuresis,
diaphoresis, chills, &
limited intake
Altered family processes
R/T to need to integrate
newborn into the family
sounds in all 4 quadrants semi-formed bowel 2. Progress diet as ordered and monitor for
or pass gas through movement by discharge tolerance
rectum 3. Encourage fluids and walking or rocking
4. Administer medication (suppository?) as
ordered
Will have soft bowel Will return to pre-delivery 1. Assess for previous pattern and problems
movement before bowel pattern within 1-2 2. Administer diet as ordered
discharge with use of weeks of delivery without 3. Teach importance of fluids, fiber, and walking
stool softeners softeners to keep stools loose and reassure these will help
with skin integrity
4. Administer xylocaine spray or pain meds as
needed
5. Administer stool softeners or other aids as
ordered
Will void 200-250 cc X 3 Will void q 2-4 hours clear 1. Assess for bladder distention and b, p, f q 4-8
within next 6-8 hours for yellow urine with burning, hrs
1st void pain, or frequency 2. Encourage to void q 2-4 hrs while awake
3. Instruct to drink to thirst and monitor color of
After the first 3-4 voids urine
the STG and LTG are the 4. Strict I & O until voids > 200 cc X 3; then
same modified I & O
5. Assist to BR as needed
6. Use “tricks” if necessary
7. Cath prn
Will maintain balanced I Will have moist mucus 1. Assess skin turgor, mucus membranes,
&O membranes, good skin 2. Monitor I & O
turgor, light yellow urine 3. Encourage to drink to thirst
4. Teach to look at color of urine
Parents verbalize 50% of Parents verbalize 1. Assess family’s learning needs, preferences
instructions without understanding or and for attachment and claiming behaviors
assistant and participate demonstrate care without 2. Identify barriers to learning
and adapt to parent hood
Acute pain _________r/t
edema, inflammation
and/or severed nerve
endings
• Perineal or incisional
• Afterbirth pain
• Hemorrhoids
• Lactation suppression
• Sore nipples
• Engorgement, etc.
Risk for infection r/t
interrupted skin barrier
and/or multiple ports of
entry and/or urinary
stasis
Risk for impaired gas
exchange r/t medication
side effects of Duramorph
(respiratory depression)
C/S DELIVERY
Risk for injury r/t
decreased mobility
secondary to epidural
anesthesia
VAG DELIVERY
Risk for impaired skin
integrity R/T disruption in
skin barrier secondary
laceration, tear, or
episiotomy or Cesarean
incision
Altered nutrition R/T
in daily care assistance and verbalize a
plan of care for home
Pain will be 3 or less on Pain will be 3 or less on
scale of 1-10 with the use scale of 1-10 with the use
of narcotic medications of OTC medications and
some narcotic medications
Temperature will remain Temperature < 100.4;
< 100.4; and incision / breath sounds clear &
perineum clean, dry & equal; voiding without b, p,
intact f; incision clean dry &
intact (because most
common noscomial
infections)
Breath sounds clear & Breath sounds clear &
equal; respiratory rate ≥ equal; respiratory rate ≥
16; color acyanotic 16; color acyanotic
Will have complete return Will not fall during
of sensation to lower hospitalization
extremities within 1-4
hours
Afebrile and skin will Afebrile and skin without
clean, dry, and intact redness, edema,
ecchymosis, or discharge
with edges intact
Blood glucose will remain Blood glucose will remain
3. Encourage rooming-in and baby care
4. Teach and reinforce as needed
1. Assess pain level q 2hrs
2. Utilize non-pharmacological methods (See
slides for specific interventions)
3. Instruct about pain management (when to ask,
methods to use, drugs available, etc.)
4. Administer medications as ordered
1. Monitor VS and lab work q 4-8 hrs
2. Assess incision or perineum q 2-4 hrs
3. Assess breath sounds and urinary staus q 4-8
hrs (noscomial infection?)
4. Aseptic technique and good hand washing
Teach patient about postpartum hygiene
1. Monitor RR q 1 hour X 24 hrs
2. Pulse ox for 24 hrs
3. Teach pt and family side effects and plan of
care
4. Have Narcan available
1. Monitor for return of feeling and motion
2. Assist to restroom first few time
3. Monitor for orthostatic hypotension
1. Assess skin q 4-8 hrs
2Apply ice after a vaginal delivery for 12 hours
according to protocol
3a. Instruct patient in sitz baths,
3b. Instruct patient and family to assess incision
daily
4. Instruct patient in peri-care, how and when to
change peri-pads and when to call HCP
1. Monitor blood sugar as ordered (ac & hs?)
imbalance of glucose and 70-110 mg/dl with the use 70-110 without the use of 2. Provide diet as prescribed
insulin utilization of sliding scale insulin insulin 3. Reinforce diabetic teaching related to diet and
(GESTATIONAL exercise
DIABETES) 4. Instruct in importance of follow up and risks for
future development of diabetes

Risk for ineffective coping Parents will verbalize Parents will verbalize Recognize importance of Rubin’s Role
R/T situational crisis feelings about birth, potential coping strategies Transition
postpartum, or newborn or support systems and 1. Encourage parents to verbalize including her
This only applies if it is problems and past coping will verbalize a plan for story and spend time with parents
a true crisis some strategies adjustment to parenthood 2. Assess for previous coping strategies and
examples are and newborn after social support
emergency delivery, discharge 3. Encourage rooming in and parents to
stillbirth, neonatal participate in care or to visit NICU and bring toys
death, newborn in or pictures
NICU, congenital 4. Assist in identifying new coping strategies and
anomalies, etc possible support services
5. Reduce unnecessary stimuli and stress
6. Refer to social services or psychological
counseling
Altered sleep patterns STG: Patient will take at LTG: Patient will verbalize Recognize period of euphoria is normal
R/T hormonal changes, least a 1-2 hour nap a plan to ensure adequate # 1 Assess prior needs for sleep and rest
blood loss, diuresis, during day rest after discharge #2 Organize nursing care and other hospital
discomfort or pain, other personnel interruptions
physical changes, baby #3 Limit or schedule visitors
care, and frequent #4 Teach to nap when baby naps, to gradually
interruptions from increase activity, and importance of diet, fluids,
hospital personnel and and vitamins
visitors #5 Medications as last resort