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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 |
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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 |
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Hydration: □ Frequency of liquid intake – how many cups a day:__________ |
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Food Weight _______ kg - Height _______ cm BMI _______ Appetite: □ maintained □ increased □ decreased Difficulty of access to food - Explain why: |
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Elimination: Urinary elimination -characteristics/frequency: ______________ □ Burning/painful sensation during urination Intestinal elimination -characteristics/frequency: ___________________ |
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Sleep and rest:□ Rest during the day □ Sleep during the day – Duration: __□ Sleep well at night – Duration: __ |
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Sexuality and reproduction: □ Postpartum sex □ Use of birth control methods - Which one: |
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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 |
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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? |
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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 |
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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_________+/++++ ____ |
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Thermical regulation Temp. _______ºC □ Does the mother usually feel cold? □ Does the mother usually have chills? |
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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 |
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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) |
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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 |
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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? |
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Recreation and leisure: Do you usually practice recreation and leisure activities? Which? |
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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 |
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Self-esteem, self-confidence, self-respect: Regarding your body image, do you feel: □ satisfied □ dissatisfied As a mother: □ satisfied □ dissatisfied |
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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? |
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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? |
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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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