Health Department
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Name of the Health Unit
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Identification data on mothers who have given birth recently
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Name:
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Area: |
Medical record no. |
Address: |
Date of 1st medical appointment _/_/_ Date of 2nd medical appointment _/_/_ |
Education level __ years |
Born on _/_/_ |
No. of children __ Age of the last child __ Gesta__Para_ |
Date of delivery___/__/___Date of hospital discharge ___/__/___ Postpartum days________ |
Delivery/birth data: □ normal □ cesarean□ forceps □ term □ preterm □ postterm |
Evaluation of the human needs of mothers who have given birth recently
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PSYCOBIOLOGICAL
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Oxygenation: FR _________rpm □ Cough □ Expectoration |
Hydration: □ Frequency of liquid intake – how many cups a day:__________ |
Food Weight _______ kg - Height _______ cm BMI _______ Appetite: □ maintained □ increased □ decreased Difficulty of access to food - Explain why: |
Elimination: Urinary elimination -characteristics/frequency: ______________ □ Burning/painful sensation during urination Intestinal elimination -characteristics/frequency: ___________________ |
Sleep and rest:□ Rest during the day □ Sleep during the day – Duration: __□ Sleep well at night – Duration: __ |
Sexuality and reproduction: □ Postpartum sex □ Use of birth control methods - Which one: |
Physical and environmental security: □ Lives in risk/violent areas Domestic hygiene conditions □ good □ regular □ poor □ Presence of insects/rodents □ Is the mother a victim of violence? Of which kind? □ emocional □ physical □ sexual Does the mother make use of □ tobacco□ alcohol □ illicit drugs |
Body care: □ Personal appearance □ good □ regular □ poor - Personal hygiene conditions □ good □ regular □ poor Domestic hygiene conditions □ good □ regular □ poor □ Does the mother do the housework? Which? |
Physical integrity: Characteristics of the skin: □ without wounds □ with wounds - local/type ______________ Tone: ______ □ Inflammation signs - local _______ Breast conditions: □ without wounds □ engorged □ turgid □ presence of abscess |
Vascular regulation TA ____x____ mmHg - FC___ bpm ou P ____ bpm □ Postpartum vaginal bleeding/lochia - Quantity □ light □ moderate □ severe Caracteristics of lochia □ sanguineous □ serosanguineous □ serosa □ purulent □ Edema - local_________+/++++ ____ |
Thermical regulation Temp. _______ºC □ Does the mother usually feel cold? □ Does the mother usually have chills? |
Neurological regulation: □ Settled in time/space □ Anxious □ Presence of affection □ Presence of attention □ Presence of good humor □ Comprehensive language □ Preserved sensorial perception □ Preserved thinking process □ Mental confusion □ Preserved memory |
Hormonal regulation: □ Uterine involution - Uterine height ______ □ Presence of milky secretion - Of type □ colostrum □ milk □ blood □ purulent - □ Does the baby look satisfied? - Glucose ________mg/dL - mg/dL- Most recent oncotic cytology □ normal □ changed - Total blood count: _________ red blood cells _____ Hg _______ Ht (pregnant card) |
Sensorial perception: □ Pain - specify □ Discomfort - specify |
Treatment and prevention: □ Does the mother use iron supplements? □ Does the mother need reference service - specify ______________ □ Does the mother have a preexisting disease? - specify _____________ □ Is the mother under some kind of treatment? - specify ______________ □ Soropositive for______□ specify __________________ □ Your family adhered to a therapeutical health service |
PSYCHOSOCIAL AND PSYCOSPIRITUAL
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Communication and social abilities: Presence of good familiar communication □ Planned parenthood □ Familiar conflict - of type __________________________________□ Presence of familiar interaction □ Do you usually trust in people? □ Are your older children happy with the baby arrival? |
Recreation and leisure: Do you usually practice recreation and leisure activities? Which? |
Emotional security: Are you facing this phase with: □ joy □ sadness □ difficulty □ fear □ security □ insecurity □ anxiety □ comfort □ discomfort □ overload □ irritation □ lots of crying for no reason □ negative feelings |
Self-esteem, self-confidence, self-respect: Regarding your body image, do you feel: □ satisfied □ dissatisfied As a mother: □ satisfied □ dissatisfied |
Freedom and participation: □ Do you have any employment bonds? □ Are you receiving the paid maternity leave? □ Are you part of some social group? |
Health education and learning: □ Exclusive breastfeeding - Specify the reason______________________ □ Do you feel the need for help while breastfeeding? - What kind of help? _________________________________________________ □ Would you like to ask something about your postpartum? ______________________________________________________________ □ Would you like to ask something about how to take care of the child? ____________________________________________________ |
Self-realization: □ Do you have the support of your family and/or friends in this new phase? □ Do you have the support of your family with the baby? |
Space: No. of rooms in the house_____ Number of family members ____ □ Do you have privacy? Where is the child sleeping? □ with the parents □ with the siblings □ in their own room □ other_________________ |
Religiosity and spirituality: □ Does the mother search for help with your spiritual problems? □ Does the mother feel good when searching for it? |
Nursing care planning to mothers who have given birth recently
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Nursing diagnosis
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Nursing intervention
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Results
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□ Changes in the mother's breathing pattern □ Productive cough |
□ Encourage the mother to cough □ Perform pulmonary auscultation □ Encourage the mother to visit the Health Unit |
□ Improved □ Worsened □ Unalterated □ Solved |
□ Inadequate liquid intake |
□ To advise the mother concerning the need for liquids intake |
□ Improved □ Worsened □ Unalterated □ Solved |
□ Poor nutrition □ Excess of body weight □ Weight loss |
□ Encourage eating habits that follow the mother's nutritional needs, food preferences and socioeconomic conditions. □ Assess the need for a change in eating habits □ Encourage dietary re-education □ Schedule an appointment with a nutritionist |
□ Improved □ Worsened □ Unalterated □ Solved |
□ Changes in the mother's urinary elimination □ Constipation |
□ Encourage the mother to control the sphincter during urination □ Advise the mother to do the exercises of Kegel □ Advise the mother on intimate hygiene □ Schedule a medical appointment □ Identify the factors that can contribute to constipation □ Do research on the mother's eating habits □ Encourage the increase in water intake □ Encourage the increase in the consumption of vegetables, fruits, and foods high in fiber. □ Encourage the mother to take walks |
□ Improved □ Worsened □ Unalterated □ Solved |
□ Fatigue □ Insomnia □ Ineffective rest □ Ineffective sleep |
□ Identify the reason for the mother's sleep disturbances □ Encourage the mother to rest □ Point out the factors that interfere in sleep, such as coffee, black tea, nicotine, soft drinks, long naps during the day, extreme temperatures, improper ventilation, inadequate lighting, noises □ Advise the mother to limit nap time from 20 to 30 minutes in the morning or afternoon □ Teach relaxation techniques □ Advise the mother to rest and sleep while the newborn sleeps □ Advise the mother to prioritize the activities □ Advise the mother to delegate activities to others |
□ Improved □ Worsened □ Unalterated □ Solved |
□ Changes in the mother's sexual pattern □ Ineffective family planning |
□ Encourage the mother's verbalization of her feelings, perceptions, and fears □ Clarify that situations of stress and the postpartum period can interfere in sex life □ Give information on the use of contraceptive methods □ Disconsider contraceptive methods for family planning |
□ Improved □ Worsened □ Unalterated □ Solved |
□ Exposure to socio-environmental violence □ Domestic violence □ Use of alcohol □ Use of tobacco □ Use of illicit drugs □ Risk of suicide |
□ Advise the mother to avoid risk behaviours □ Assess the environmental hygiene conditions during the follow-up visit □ Give information on the consequences of using tobacco, alcohol and/or drugs not only for herself bur also for the child □ Identify if the mother has family and community support □ Advise the mother to attend to heath services for women victims of violence □ Advise the mother to participate of a support group □ Identify risk of suicide □ Establish a support relationship □ Involve the family in the support and monitoring of the mother □ Communicate situations of violence to the competent authority □ Advise the mother to attend a medical appointment |
□ Improved □ Worsened □ Unalterated □ Solved |
□ Inadequate self-care: bathing/hygiene and clothing |
□ Encourage habits of hygiene and clothing according to the mother's conditions and to the weather □ Advise the regular exchange of postpartum sanitary napkins |
□ Improved □ Worsened □ Unalterated □ Solved |
□ Breast engorgement □ Nipple fissures □ Breast inflammation □ Contaminated surgical wound □ Changes in skin tone (specify local) □ Risk for impaired tissue integrity □ Infection (specify local) |
□ Hand express breastmilk □ Offer the milk to the child with a small spoon or cup □ Advise breast exposure to the sun: 15 minutes in the morning before 10 a.m., or in the afternoon after 4 p.m. □ Cleaning of the nipple with breast milk before and after feeding the baby □ Discourage the excessive handling of the nipples □ Discourage the use of soap, cream, and ointment in the nipples □ Advise that hands need to be washed before handling the breasts □ Monitor the healing process of the surgical wound □ Put a dressing in the infected surgical wound □ Monitor signs of infection □ Examine episiorrhaphy |
□ Improved □ Worsened □ Unalterated □ Solved |
□ Edema □ Lochia (specify the type and if the case is light, moderate, severe) □ Increased blood pressure |
□ Put the mother's legs up □ Examine pulse timing characteristics □ Examine uterine involution □ Observe lochia characteristics □ Monitor liquid loss □ Request for total blood count test □ Treat cases of anaemia □ Guide the bleeding cases identified in follow-up visits to the Health/Maternity Unit □ Minister antihypertensive drugs □ Control blood pressure □ Give information on the preventive measures to avoid the increase of blood pressure |
□ Improved □ Worsened □ Unalterated □ Solved |
□ Increased body temperature |
□ Check body temperature □ Minister antipyretic drugs □ Keep the mother warm □ Encourage liquid intake □ Guide the mother to the Health Unit if the fever persists |
□ Improved □ Worsened □ Unalterated □ Solved |
□ Anxiety □ Changes in mental activities: level of conciousness □ Changes in mental activities: orientation (time, space, self, others) □ Confusion |
□ Assess the mother-child relationship □ Assess the changes in the level of consciousness □ Investigate the presence of factors that contribute to mental confusion □ Keep the mother informed about people, time, space □ Avoid asking questions that the mother may not know how to answer □ Keep the mother located in time and space (give her things such as a clock, a calendar, a mirror) □ Plan playful activities to stimulate the memory □ Use simple sentences during communication □ Involve the family in the recovery process of the mother's mental capacities □ Stimulate physical leisure activities □ Guide the mother to a Mental Health Unit |
□ Improved □ Worsened □ Unalterated □ Solved |
□ Retarded uterine involution □ Low milk supply □ Unstable blood glucose |
□ Give information on the observation of lochia (characteristics and quantity) □ Examine uterine involution □ Help the mother during lactation □ Explain the physiological changes involving decreased lactation □ Advise the mother to let the child suck freely □ Verify capillary blood glucose □ Give information on the importance of monitoring blood glucose □ Give information on the signs and symptoms of hypoglycemia and hyperglycemia □ Guide the mother to the Health Unit/Hospital |
□ Improved □ Worsened □ Unalterated □ Solved |
□ Pain (specify local and intensity) |
□ Encourage the mother to complain when she feels pain □ Help the mother to relieve her pain □ Guide the mother to attend a medical appointment |
□ Improved □ Worsened □ Unalterated □ Solved |
□ Maintenance of altered health □ Inadequate adhesion to the treatment □ Inadequate adhesion to the diet |
□ Involve the family in the resolution of the mother's health problems □ Encourage the mother to take part of groups □ Give information on the therapy to be followed □ Give information on the diet to be followed |
□ Improved □ Worsened □ Unalterated □ Solved |
□ Ineffective familiar communication □ Conflicting attitutes among family members □ Inadequate social interaction □ Potential for inadequate fatherhood/motherhood □ Risk of social isolation □ Risk of feeling lonely |
□ Asses the family's support dynamics □ Identify the communication barrier of the family □ Suggest opportunities for family members to get together and discuss the situation □ Observe the mother's and child's behaviour during breastfeeding □ Observe the interaction father/mother/children □ Help the development of especial abilities □ Help the family to recognize the strong points in their relationship □ Encourage the interaction with friends, family, and community groups □ Guide the mother to family counseling |
□ Improved □ Worsened □ Unalterated □ Solved |
□ Insufficient recreation and leisure activities |
□ Identify social facilities for recreation and leisure activities □ Encourage the participation in recreation and leisure activities |
□ Improved □ Worsened □ Unalterated □ Solved |
□ Anxiety □ Postpartum depression □ Fear (specify) □ Hopelessness □ Feeling incapable □ Sadness |
□ Assess behaviors that might indicate anxiety □ Give information on the emotional changes in puerperium □ Help the mother to relax □ Help the mother to identify a supportive system □ Develop a supportive relationship with the mother □ Develop a relationship with the family □ Involve the family in the mother's care and in household activities □ Monitor symptoms of postpartum depression □ Guide the mother to a Mental Health Unit |
□ Improved □ Worsened □ Unalterated □ Solved |
□ Low self-esteem □ Little trust in others |
□ Stimulate maternal self-confidence □ Give information on personal care □ Help the mother to identify her positive qualities and possible opportunities □ Observe changes in self-esteem □ Discuss the predictable physical alterations with the mother □ Explain the process of self-image recomposition □ Reinforce the positive aspects □ Promote active listening □ Encourage visits from friends, relatives and significant people □ Help with establishing realistic goals |
□ Improved □ Worsened □ Unalterated □ Solved |
□ Low initiative □ Lack of willpower □ Indecision □ Limited citizenship rights (specify) □ Inadequate decision-making process |
□ Help family members to assess their own behaviour □ Encourage the freedom to express feelings □ Encourage the decision-making process |
□ Improved □ Worsened □ Unalterated □ Solved |
□ Insufficient knowledge on postpartum related aspects □ Insufficient knowledge on breastfeeding □ Insufficient knowledge on newborn care □ Inadequate knowledge (specify the topic: health condition, medications, exams, treatments, among others) □ Inadequate use of contraceptive methods |
□ Give information on the care of surgical wounds/episiorrhaphy □ Encourage exclusive breastfeeding □ Teach the process of hand expressing and storing breast milk □ Observe breastfeeding and how the mother handles the breasts □ Teach the right positioning of the newborn during breastfeeding □ Teach the mother a comfortable position for breastfeeding □ Stimulate the mother to breastfeed according to the child's demand □ Help the mother to breastfeed □ Give information on the nutritional needs of the newborn □ Give information on the need for breastfeeding in a calm location □ Talk about the myths and beliefs around breastfeeding □ Identify people that can help with the breastfeeding process □ Give information on the care of breasts and nipples □ Explain contraception methods □ Help the mother to identify the informations she is more interested in □ Advise the mother to return to the Health Unit, and give information on the child's vaccination schedule and on the monitoring of the child's growth and development |
□ Improved □ Worsened □ Unalterated □ Solved |
□ Conflicting performance of the parents' role as mother/ father □ Ineffective performance |
□ Encourage the parents to express their feelings and concerns □ Assess the impact of child birth on the parents role and relationships □ Encourage the participation of the parents in child care □ Give information on the child's health conditions to the parents □ Advise the mother on the importance of the mother-father-child relationshio □ Count on other family members in child care |
□ Improved □ Worsened □ Unalterated □ Solved |
□ Lack of privacy □ Inadequate personal space |
□ Advise the parents to have a private space □ Explain to the family the mother's need for privacy □ Advise the use of home spaces to respect the family members need for privacy |
□ Improved □ Worsened □ Unalterated □ Solved |
□ Anguish □ Perception of the lack of meaning in life |
□ Assess the family's spiritual beliefs □ Support the mother's or the family's spiritual practices □ Encourage the expression of feelings concerning life, ego, emotion, subjectivity, beliefs, myths, expectations, among others □ Talk about the visit of the spiritual leader at home |
□ Improved □ Worsened □ Unalterated □ Solved |
Observations |
Nurse: |
COREN: |
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