Living situation and family support: Understanding who the patient lives with, their support system, and any caregivers involved.

Please complete the Clinical judgment plan document. You can make up the patient make sure she is from labor and delivery unit and that she does not not have too many complications. if something doesn’t apply to he please do not put n/a and instead say something like pun relieving her chart this was not found or something like that. next I will send all the examples and announcements my teacher posted PLEASE READ ALL OF THEM. IF YOU DO OT HAVE ENOUGH SPACE TO WRITE PLEASE DON”T CHANGE THE FONT SIZE USE A SEPERTE DOCUMENT AND JUST WRITE ON THE PDS SEE DOCUNENT AND TITLE THE DOCUMENT thank you!
Examples Social History Tips for CJP
Social History Tips for CJP
Future RN’s , as healthcare professionals, it’s essential to recognize that all patients have a social history that is integral to their health and care. This history, which provides important context about a patient’s lifestyle, environment, and social factors, is a key part of our role. By understanding how external factors such as family support, occupation, education, and substance use may influence a patient’s health outcomes and recovery process, we can fully engage in our commitment to their care.
What should be included in a patient’s social history:
Living situation and family support: Understanding who the patient lives with, their support system, and any caregivers involved.
Occupation and education: The patient’s job or educational status can influence their stress levels, access to healthcare, and ability to follow treatment plans.
Substance use: Whether the patient uses alcohol, tobacco, or drugs, and if so, how frequently.
Religious and cultural beliefs: These can impact healthcare decisions, especially regarding treatments, end-of-life care, or coping strategies.
Insurance and financial status: To assess healthcare services or medication barriers.
Lifestyle factors: Including diet, exercise habits, and any high-risk behaviors that might affect health.
This history provides a holistic view of patients beyond their medical conditions, helping nurses offer more personalized, empathetic care.
If the patient does not drink, do drugs, or smoke, state that.
Example Social History:
The patient is a 20-year-old Hispanic female who recently gave birth to her first child via cesarean section due to failure to progress in labor. The baby’s father is not involved in her life or the care of the newborn. She identifies as Catholic, and her faith plays a significant role in her coping strategies and emotional well-being during the postpartum period. The patient is a full-time student, which poses potential challenges in balancing her education with the demands of new motherhood.
She resides with her paternal father and grandmother, who provide substantial emotional and financial support. This family structure helps mitigate some of the stressors of being a young, single mother. However, the absence of the baby’s father may contribute to feelings of isolation or additional emotional burden. Despite these challenges, the patient appears resilient and motivated to provide the best care for her child, though she may require continued support in areas such as breastfeeding and newborn care.
The patient denies any history of drug use, alcohol consumption, or smoking. She is covered by Medi-Cal, a state-funded health insurance program that alleviates the financial strain of medical care. However, due to potential limitations of this coverage, she may face challenges accessing certain services or resources. Given her age, education status, and family situation, there may be financial concerns in the long term, especially as she transitions back to school and childcare becomes a necessity.
Examples: Evaluation OB CJP
Evaluation:
Evaluate each outcomes (4) if goal not met what further action is needed.
Examples:
Risk for Infection
The patient remained free from infection during her hospital stay, as evidenced by an average WBC count (<11.0 x 10^9/L), absence of fever, and no signs of infection at the incision or breast sites. She demonstrated correct wound care and hand hygiene, effectively preventing infection. Early ambulation helped reduce the risk of complications such as pneumonia or DVT, and no antibiotics were needed. The goal of maintaining a stable, infection-free recovery within 72 hours was successfully met.
Acute Pain
The patient’s pain decreased to a manageable level of 3/10 within 24 hours, allowing her to ambulate and breastfeed with minimal discomfort. Pain management through a combination of non-opioid and opioid medications, along with non-pharmacological measures like cold therapy
for the incision and warm compresses for breast pain, was effective. The patient’s pain was assessed, and interventions were adjusted accordingly. She was able to breastfeed with reduced nipple trauma, and overall pain management goals were met within the first 24 hours.
3. Impaired Breastfeeding
Within 24 hours, the patient demonstrated effective breastfeeding techniques, including proper latch. She followed the lactation consultant’s advice and successfully managed breast engorgement by breastfeeding or pumping every 2-3 hours. Nipple bruising improved with the use of lanolin, and there were no signs of infection or worsening trauma. The infant fed effectively, and the patient expressed confidence in breastfeeding post-discharge. The goal of establishing successful breastfeeding and resolving physical challenges was achieved within the designated time frame.
4. Fluid Volume Deficit Related to Postpartum Hemorrhage
The hemoglobin and hematocrit levels improved to within normal limits, and her vital signs remained stable. She experienced no dizziness or fatigue and maintained proper hydration with adequate oral intake. IV fluids helped restore fluid volume, and oral iron supplements contributed to improved hemoglobin levels. The patient showed no signs of dehydration or further fluid imbalance, and the goal of stabilizing fluid volume and anemia was achieved within 72 hours.

Examples: Take Action for OB CJP
Take Action
Here is an example:
Here is a detailed bullet point list of nursing actions for the patient, M.A. after NSVD using the principles of nursing care, priorities, and planned outcomes. The interventions focus on promoting, maintaining, and restoring her health while considering her developmental stage (Erikson’s Generativity vs. Stagnation stage):
Assess fundus every 15 minutes.
Perform fundal massage as needed.
Monitor perineal pad saturation hourly.
Encourage early ambulation within 12 hours.
Assess for large clots or hemorrhage.
Monitor vital signs every 4 hours.
Administer prescribed uterotonics as ordered.
Teach signs of postpartum hemorrhage.
Encourage hydration to maintain fluid volume.
Evaluate hemoglobin levels as per protocol.
Initiate skin-to-skin contact immediately.
Provide lactation consultation within 12 hours.
Assist with proper latch positioning.
Observe the infant’s feeding and sucking patterns.
Teach effective breastfeeding techniques.
Encourage breastfeeding 8-12 times daily.
Monitor infant weight gain and wet diapers.
Address the mother’s breastfeeding concerns and fears.
Reinforce proper positioning and latch adjustments.
Provide educational materials on breastfeeding.
Perform hand hygiene before perineal care.
Teach proper perineal hygiene techniques.
Monitor lochia for abnormal color or odor.
Assess the perineal area for signs of infection.
Educate the patient on changing perineal pads frequently.
Monitor WBC count for infection signs.
Encourage the use of peri-bottle after urination.
Teach to avoid tampons during the postpartum period.
Instruct on reporting fever or foul-smelling discharge.
Administer prescribed antibiotics if indicated.
Perform pain assessments every 4 hours.
Offer ice packs for perineal discomfort.
Administer NSAIDs or analgesics as prescribed.
Encourage early gentle ambulation.
Provide education on pain relief strategies.
Offer warm compresses to relieve cramping.
Teach relaxation techniques for pain control.
Monitor pain response to interventions.
Encourage position changes to alleviate discomfort.
Evaluate the effectiveness of the pain management plan.
Acknowledge work-life balance concerns.
Discuss body image changes postpartum.
Offer emotional support for family role strain.
Refer to support groups for new mothers.
Involve the husband in care planning.
Encourage participation in parenting discussions.
Reinforce positive contributions to family life.
Provide reassurance about physical recovery.
Address anxiety about postpartum adjustments.
Facilitate discussions on managing family dynamics.
These nursing actions, aimed at preventing complications and promoting recovery, align with the patient’s health deviations and reflect her developmental stage as a mother of three who balances personal, family, and professional life.
Here is another example Take Action:
Here is a list of essential nursing interventions aimed at the expected outcomes and directed at PIH when caring for a pregnant patient with preeclampsia:
Monitoring Vital Signs not just BP
Assessing for Symptoms and Complications
Check for edema (especially in hands, face, and lower extremities).
Monitor for sudden weight gain.
Ask about headaches, visual disturbances (blurred vision, floaters), or right upper quadrant pain (indicative of liver involvement).
Assess for shortness of breath or chest pain (suggestive of pulmonary edema).
Monitoring Urine Output and Protein Levels
Measure urine output (alert if <30 mL/hour).
Perform urine tests for proteinuria.
Fetal Monitoring
Conduct non-stress tests or continuous fetal heart rate monitoring as ordered.
Monitor for decreased fetal movements and signs of fetal distress.
Administering Medications as Prescribed
Administer antihypertensive medications (e.g., labetalol, hydralazine) as ordered.
Administer magnesium sulfate for seizure prevention and monitor for toxicity (reflexes, respiratory rate, and urine output).
Keep calcium gluconate at the bedside as an antidote for magnesium toxicity.
Educating the Patient and Family
Educate about the condition, potential complications, and importance of reporting symptoms promptly.
Teach signs of worsening preeclampsia (e.g., headache, blurred vision, decreased fetal movement).
Monitoring Laboratory Values
Check platelet counts, liver enzymes, and renal function regularly (alert if abnormal).
Monitor hematocrit and hemoglobin levels to detect hemoconcentration.
Promoting Rest and Managing Environment
Encourage bed rest or limited activity as prescribed to lower blood pressure.
Provide a quiet environment to reduce stimuli and prevent seizures.
Seizure Precautions
Keep the side rails padded and in the up position.
Have oxygen and suction equipment readily available.
Monitor for signs of impending eclampsia (hyperreflexia, clonus, severe headaches).
Fluid Management
Administer IV fluids cautiously to prevent fluid overload.
Maintain strict intake and output monitoring.
Preparing for Delivery if Necessary
Be prepared for induction of labor or emergency delivery if maternal or fetal conditions worsen.
Collaborate with the healthcare team to ensure safe delivery planning.
Emotional Support
Offer reassurance and emotional support to reduce anxiety.
Include the patient’s family or support system in care when appropriate.

Examples:Generation of solutions (Planning) for OB CJPGeneration of solutions (Planning) example for CJPBased on your patient’s case established priorities of care, here are examples of four expected outcomes, each with specific, measurable, realistically attainable, and timely (SMART) criteria. Each outcome is followed by four nursing interventions supported by evidence-based practice and scientific rationale with citations. Four nursing intervention for each Expected Outcome for a total of 16 interventions with citations. Please use an additional page as a word doc.Outcome 1: Maintain Circulation and Hemodynamic StabilityExpected Outcome:Within the first 2 hours postpartum, A.C. will maintain stable blood pressure (within 10% of baseline), heart rate (60-100 bpm), and adequate urinary output (at least 30 mL/hr), indicating hemodynamic stability without signs of hemorrhage.Nursing Interventions:
Monitor Vital Signs Frequently (Every 15 Minutes Postpartum): Regular monitoring of blood pressure, heart rate, and oxygen saturation can help identify early signs of hemodynamic instability or hemorrhage. Monitoring closely can help initiate rapid interventions if needed (Jiang et al., 2020).
Assess Uterine Tone and Position Postpartum: Regular palpation of the fundus helps determine if the uterus is firm and well-contracted, which is crucial in preventing postpartum hemorrhage. A boggy uterus indicates the need for uterotonic medications or further intervention (Sentilhes et al., 2021).
Administer Uterotonic Medications as Ordered: Medications such as Oxytocin or Misoprostol effectively reduce the risk of postpartum hemorrhage by promoting uterine contractions (Widmer et al., 2018).
Encourage Early Ambulation if Stable: Early ambulation post-delivery can help improve circulation and prevent venous thromboembolism, a postpartum risk. Encourage A.C. to ambulate with assistance as soon as she is stable (Sultan et al., 2021).
Outcome 2: Effective Pain Management and ComfortExpected Outcome:A.C. will report a pain level of less than 3 out of 10 within 2 hours postpartum through appropriate pain management strategies.Nursing Interventions:
Assess Pain Using a Validated Pain Scale Every Hour: Regular pain assessments help guide the effectiveness of interventions and ensure timely adjustments in pain management plans (Chou et al., 2016).
Administer Prescribed Analgesics and Assess Their Effectiveness: Medications like NSAIDs and opioids (if necessary) should be administered as ordered, and their effectiveness should be evaluated to ensure adequate pain relief without adverse effects (American Pain Society, 2019).
Encourage Non-Pharmacological Pain Relief Methods: Techniques such as deep breathing, positioning, and warm compresses can complement pharmacologic interventions to reduce pain perception (Smith et al., 2018).
Promote Skin-to-Skin Contact with Newborns: Skin-to-skin contact releases oxytocin, which promotes relaxation and reduces pain perception in postpartum mothers (Dabrowski, 2019).
Outcome 3: Prevention of Postpartum Depression (PPD)Expected Outcome:A.C. will verbalize understanding of PPD risk factors, symptoms, and available support resources before discharge and will be referred to postpartum support services if needed.Nursing Interventions:
Conduct Regular Mental Health Screenings Using a Validated Tool: Tools such as the Edinburgh Postnatal Depression Scale (EPDS) help identify women at risk for PPD early in the postpartum period (O’Hara & McCabe, 2013).
Provide Education on PPD Symptoms and Resources: Educate A.C. on the signs and symptoms of PPD and available resources, including counseling and support groups, to promote early recognition and intervention (Dennis & Hodnett, 2017).
Facilitate Family Involvement in Emotional Support: Encourage family members, especially the spouse, to be involved in providing emotional support, which is crucial in mitigating the risk of PPD (Dix et al., 2019).
Offer Culturally Sensitive Counseling Services: Referrals to culturally sensitive mental health services, especially in Spanish, ensure that A.C. receives comprehensive care aligned with her cultural background (Goyal et al., 2015).
Outcome 4: Promote Adequate Postpartum Nutrition and Hydration to Support Healing and LactationExpected Outcome:Within 24 hours postpartum, A.C. will demonstrate an understanding of the importance of adequate nutrition and hydration to support healing and lactation by verbalizing dietary requirements and consuming balanced meals and fluids as appropriate.Nursing Interventions:
Provide Education on Postpartum Nutrition and Hydration Needs: Educate A.C. on the importance of a well-balanced diet rich in protein, vitamins, and minerals to promote healing and support lactation. Adequate hydration is essential, especially for breastfeeding mothers, to ensure sufficient milk supply and prevent dehydration (Rudrappa, 2020). Tailoring the education to A.C.’s cultural preferences will ensure better adherence.
Collaborate with a Dietitian to Develop a Postpartum Nutrition Plan: A referral to a dietitian can help create a personalized nutrition plan that considers A.C.’s gestational diabetes and promotes stable blood glucose levels. This plan should focus on balanced meals with controlled carbohydrate intake to manage blood sugar and promote recovery (Ebrahimi-Mameghani et al., 2019).
Encourage Frequent, Small Meals and Snacks to Maintain Energy Levels: Encourage A.C. to consume small, frequent meals throughout the day to maintain energy levels, particularly when caring for a newborn. This approach can prevent hypoglycemia, especially in gestational diabetes, and ensure consistent nutrient intake to support recovery and lactation (Kominiarek et al., 2018).
Monitor and Encourage Adequate Fluid Intake (2-3 Liters per Day): Encourage A.C. to drink 2-3 liters daily to stay hydrated, support milk production, and promote overall recovery. Adequate hydration is crucial for lactation, as it directly affects milk supply (Haider et al., 2020). Monitor signs of dehydration, especially if A.C. is breastfeeding and losing fluids.
Another example Generate Solutions:Generate Solutions:Here are four expected outcomes and corresponding solutions for each of the hypotheses identified for the patient supported by evidence-based practice:Fluid Volume Deficit Related to Postpartum HemorrhageExpected Outcome:The patient’s hemoglobin and hematocrit levels will improve to within normal limits (HGB ≥ 12 g/dL and HCT ≥ 36%) within 72 hours, and the patient will show no signs of hypovolemia (e.g., stable vital signs, absence of dizziness or pallor).Solutions:
Monitor Vital Signs and Labs Regularly
Monitor hemoglobin, hematocrit, and vital signs (blood pressure, heart rate) every 4 hours to detect changes in fluid balance and signs of ongoing blood loss. (EBP Source: NICE Guidelines on Postpartum Hemorrhage, 2017)
IV Fluid and Blood Products as Necessary
Administer IV fluids and blood transfusions as prescribed to restore circulating blood volume and improve oxygenation. (EBP Source: ACOG Postpartum Hemorrhage Guidelines, 2020)
Encourage Oral Hydration
Encourage the patient to drink fluids regularly to support recovery and maintain hydration. (EBP Source: Cochrane Database of Systematic Reviews, 2018)
Iron Supplementation for Anemia
Educate patient on taking iron supplements as ordered by OB to correct postpartum anemia, if necessary. Oral or IV iron may be indicated depending on severity. (EBP Source: WHO Guidelines for Anemia in Postpartum Women, 2019)Risk for InfectionExpected Outcome:The patient will remain free of infection, as evidenced by normal WBC count (<11.0 x 10^9/L), afebrile status, and no signs of incisional or breast disease (e.g., redness, swelling, purulent drainage) within 72 hours of cesarean section.Solutions:
Maintain Surgical Site Cleanliness
Postoperative wound care (cleansing the incision with sterile saline and keeping it dry) reduces the risk of infection. (EBP Source: WHO Surgical Site Infection Guidelines, 2016)
Hand Hygiene Education
Instruct the patient and family on proper handwashing techniques to minimize pathogen transfer. (EBP Source: CDC Hand Hygiene Guidelines, 2002)
Early Mobilization
Encourage early ambulation to enhance circulation and reduce the risk of infections like pneumonia or DVT. (EBP Source: Cochrane Review, 2017)
Antimicrobial Therapy if Indicated
Administer prophylactic antibiotics post-cesarean if signs of infection are present. (EBP Source: ACOG Guidelines for Cesarean Delivery, 2018)Acute PainExpected Outcome:The patient will report pain reduction to a manageable level of 3/10 or less within 1 hour of pain management interventions.Solutions:
Administer Analgesics as Prescribed
Rationale: Use multimodal analgesia, combining non-opioid pain relievers (like acetaminophen and ibuprofen) with opioids as needed, to provide effective pain relief. (EBP Source: WHO Pain Relief Ladder, 2020)
Non-Pharmacological Interventions (Positioning, Cold/Heat Therapy)
Encourage the use of non-pharmacologic interventions like cold compresses on the incision site or warm compresses for engorged breasts to manage discomfort. (EBP Source: Journal of Pain Research, 2019)
Lactation Support for Breast Pain
Provide lactation support to ensure proper latch and prevent further breast or nipple trauma. (EBP Source: Lactation Support and Counseling Guidelines, 2015)
Monitor Pain Levels Regularly
Regularly assess pain levels using a standardized scale and adjust medications or interventions as needed. (EBP Source: JCAHO Pain Management Standards, 2017)Impaired BreastfeedingExpected Outcome:The patient will demonstrate effective breastfeeding techniques, including proper latch, within 24 hours, as evidenced by decreased breast engorgement, absence of nipple trauma, and appropriate infant weight gain during breastfeeding sessions.Solutions:
Lactation Consultant Referral
Refer to a lactation consultant within 24 hours postpartum to provide education and hands-on assistance with positioning and latch, which can improve breastfeeding outcomes. (EBP Source: Cochrane Review, 2020)
Frequent Breastfeeding or Pumping
Encourage breastfeeding or pumping every 2-3 hours to prevent engorgement and stimulate milk production. (EBP Source: American Academy of Pediatrics (AAP) Breastfeeding Guidelines, 2018)
Education on Breast Care
Teach the patient to alternate breasts during feedings and apply warm compresses before feeding and cold compresses after to relieve engorgement. (EBP Source: Journal of Obstetric, Gynecologic & Neonatal Nursing, 2019)
Assess and Address Nipple Trauma
Apply lanolin ointment or breast milk to bruised nipples after feedings to promote healing and prevent further injury, assess for appropriate latch (EBP Source: AWHONN Guidelines on Breastfeeding, 2017)These expected outcomes and solutions are designed to ensure that the patient’s physical and emotional needs are met efficiently, with care based on evidence-based guidelines. By implementing these strategies, nursing care can significantly contribute to the patient’s positive postpartum recovery.

Examples: Analyze cues for CJPExamples: Analyze cues for CJPTake the cues you have listed in “Recognize Cues” and Analyze them so that you can group/cluster the CuesPain Management:Cues:
Pain rated at 7/10
administration of morphine
epidural placement.
Gestational Diabetes Management:Cues:
History of gestational diabetes
glucose levels within normal limits (WNL)
baby’s blood sugar at 50 mg/dL.
Labor Progression and Delivery Monitoring:Cues:
Cervical dilation progression (4 cm to 10 cm)
External monitoring (fetal heart rate of 120 with moderate variability)
contraction pattern (every 2-3 minutes).
Postpartum Hemorrhage Prevention and Management:Cues:
Estimated blood loss of 450 mL
administration of Pitocin (10 units I.M.)
400 mL bolus of Lactated Ringer.
Bladder and Bowel Function Post-Delivery:Cues:
Inability to void after delivery
Foley catheter placed
urine output was 40 mL/hr
hypoactive bowel sounds.
Psychosocial Support and Mental Health:Cues:
Strong family support noted
risk of postpartum depression (PPD)
cultural importance of family
religious practices.
Cultural and Language Considerations:Cues:
Hispanic ethnicity
Spanish-speaking
Catholic faith.
Vital Signs Monitoring and Stability:Cues:
BP 125/80
R. 78
R. 16
O2 Sat 98% on room air
Temp 36.5°C.
Family Involvement and Education:Cues:
Husband supportive
Expecting other children to visit.
Another example:Analyze CuesRemember you are using the cues from recognize cues and grouping/clustering that establishes probable patient needs, concerns, or problems. I included the concerns and probable needs to indicate the train of thought for clustering/grouping the cues. All that is required is clustering the cues. Whats in blue is to provide an explanationHistory of Intimate Partner Violence (IPV)Recognize Cues:
History of IPV
Spanish-speaking only
Concerns: Emotional trauma, communication barriers, and potential social/family stressors.Probable Needs: Psychological support, language services (interpreter), and referral to social services.Infection and Immune ConcernsRecognize Cues:
Hepatitis C positive
HSV positive
Concerns: Potential infection risk for the infant, transmission concerns, and monitoring of symptoms postpartum.Probable Needs: Infectious disease consultation, patient education regarding breastfeeding and infection prevention, and maternal and infant testing follow-up.Postoperative Care after Cesarean SectionRecognize Cues:
Incisional tenderness
pain 7/10
unilateral breast engorgement
hypoactive bowel sounds
full bladder
Concerns: Pain management, risk of postoperative complications (e.g., infection, ileus), urinary retention.Probable Needs: Adequate pain control, wound care, bladder assessment, encouraging mobility, and bowel management.Anemia and Hemodynamic ConcernsRecognize Cues:
WBC 12.3
RBC 3.12
HGB 9.1
Hct 27.1
trace edema
Concerns: Postpartum anemia, risk of infection, potential fluid imbalances.Probable Needs: Monitoring hemoglobin/hematocrit levels, possible blood transfusion or iron supplementation, assessment for infection, and management of edema.Nutritional and Gastrointestinal ConcernsRecognize Cues:
Constipation
hypoactive bowel sounds
full bladder on palpation
limited prenatal care at 21 weeks
Concerns: Bowel dysfunction due to anesthesia/surgery, limited nutrition intake, dehydration.Probable Needs: Bowel regimen, dietary consultation, hydration monitoring, and gradual reintroduction of solid foods.Breastfeeding and Infant Care ChallengesRecognize Cues:
Limited infant interaction/exposure before birth
unilateral nipple bruising
unilateral breast engorgement
Concerns: Difficulty with breastfeeding, improper latch, risk of mastitis.Probable Needs: Lactation consultant support, teaching on proper breastfeeding techniques, monitoring for signs of infection.Cardiovascular and Respiratory ConcernsRecognize Cues:
Chest pain
trace edema
Concerns: Potential cardiovascular strain postpartum, fluid retention.Probable Needs: Cardiac evaluation, monitoring vital signs, and managing any underlying respiratory or circulatory issues.Psychosocial and Language BarriersRecognize Cues:
History of IPV (1),
Spanish-speaking only
limited prenatal care at 21 weeks
limited infant interaction/exposure
Concerns: Social isolation, lack of prenatal education, and difficulty understanding discharge instructions.Probable Needs: Interpreter services, postpartum depression screening, education on newborn care, and linking the patient with community resources.Summary of Needs:
Psychosocial: Psychological support, interpreter, social services referral.
Postoperative: Pain management, wound care, monitoring for infection.
Infection Prevention: Education on breastfeeding with Hepatitis C/HSV and infection risk management.
Breastfeeding Support: Lactation consultant for breastfeeding difficulties.
Nutritional: Bowel regimen, dietary support.
Cardiovascular/Respiratory: Monitor for potential cardiovascular strain chest pain evaluation.
Anemia Management: Follow-up labs are a potential treatment for anemia.
Example: Recognition of cues (Assessment) for CJPExample: Recognition of cues (Assessment) for CJPRecognition of cues:(Assessment)Identifies all imperative cues taken from the environment, patient assessment/observation, medical record, other resources, time pressures, task complexity, and cultural considerations.A minimum of 15 cues is required. List the cues using bullet points.Using the information from the patient, here’s a list of imperative cues taken from the environment, patient assessment/observation, medical records, other resources, time pressures, task complexity, and cultural considerations for the patient.
Presence of a supportive husband
Skin-to-skin contact with newborn
Hospital labor and delivery unit setting
Pain level: 7/10 before pain management
Abdominal pain due to cramping
Spontaneous rupture of membranes
Gestational diabetes history
Random glucose 90
Obesity
Blood type O+
Prenatal panels negative for infections
Monitoring of vitals every 15 minutes post-delivery
Managing pain and monitoring fluid intake/output
Administering Pitocin and fluids for hemorrhage control
Administered morphine
Epidural
Hispanic ethnicity
Catholic religion; Bible reading and church attendance
Strong family support system noted
P.: 125/80
R.: 78
R.: 16
Temp: 36.5°C
O2 Sat: 98% on room air
Vaginal delivery with 1 degree laceration
Estimated blood loss: 450 mL
History of postpartum depression
Spanish-speaking patient
Economic stability concerns due to part-time work and maternity leave
Hypoactive bowel sounds
Bloated and tender abdomen
Ensure language-appropriate resources and culturally sensitive care
Family involved
unable to void after delivery
Foley catheter
These cues cover the imperative aspects of the patient’s care and situation, considering her medical history, labor and delivery process, and cultural and psychosocial factors.
https://westcoastuniversity.hosted.panopto.com/Panopto/Pages/Viewer.aspx?id=0c629271-3c58-4fe7-b8c7-b19f014044f3
Examples: Socioeconomic, Psychosocial, and Cultural Assessment & Psychosocial Concerns
Examples: Socioeconomic, Psychosocial, and Cultural Assessment & Psychosocial Concerns
Hi everyone!
I understand that pinpointing three psychosocial concerns can be tricky, especially when it appears that a patient might not have any. To help you out, I have put together a list of potential psychosocial concerns that a mom might experience during labor and postpartum. I am also including an example to guide you but remember, this example focuses on a first-time Hispanic mom who just had a baby and has a supportive husband working as a legal secretary. Your patient’s circumstances might differ, so this may not directly apply.
If you’re having trouble or need some more ideas tailored to your specific patient, please don’t hesitate to contact me. I am here to help!
When detailing the socioeconomic and cultural background of a Hispanic woman who has just delivered her first baby vaginally, it is essential to consider the various factors that uniquely influence her experience. This woman works as a legal secretary, typically managing legal documents, supporting attorneys, and possibly interacting with clients, suggesting a middle socioeconomic status. Her husband’s supportive nature is also crucial, as it can significantly impact her postpartum experience.
Please identify a minimum of 3 for your CJP
Labor and delivery, as well as the postpartum period, can be filled with a mix of emotions and potential psychosocial concerns. Here are several concerns that patients might experience during these times:
Anxiety and Fear: Fear of childbirth, concerns about the baby’s health, and fear of pain or complications during delivery are common. Postpartum anxiety can also emerge, focusing on the baby’s care and the ability to cope with motherhood.
Depression: Postpartum depression affects many women and can manifest as sadness, lethargy, feelings of hopelessness, and disinterest in the baby. Less commonly, perinatal depression can occur during pregnancy.
Stress: Labor, changes in routine, lack of sleep, and the responsibilities of caring for a newborn can be overwhelming. This stress can also stem from managing the expectations of motherhood and personal recovery.
Body Image Concerns: Many women experience changes in their self-esteem and body image due to physical changes during and after pregnancy.
Social Isolation: Feeling cut off from social networks and support systems can occur, especially if there are restrictions on visitors (as seen during the COVID-19 pandemic) or if the family lives far away.
Relationship Strain: Changes in relationships with a partner or spouse can arise as both adjust to new parental roles. This might include conflicts over parenting styles, division of labor, and lack of intimacy.
Financial Stress: Concerns about healthcare costs, childcare, and potentially reduced income if taking unpaid maternity leave or quitting a job to care for the child.
Trauma: Birth trauma, which may be physical or emotional, can result from difficult labor, emergency interventions, or delivery that did not go as planned. This can lead to lasting fear or reluctance about future childbirth.
Grief and Loss: In cases where there are complications such as miscarriage, stillbirth, or neonatal death, profound grief and mourning can impact the psychological well-being of parents.
Cultural Pressure: Cultural expectations and practices related to childbirth and parenting can cause stress, especially if these expectations clash with personal beliefs or the advice of healthcare providers.
Addressing these concerns with supportive care, appropriate counseling, and resources can help mitigate the impact on new mothers and their families.
Example:
Socioeconomic and Cultural Background
Employment and Economic Status: As a legal secretary, the woman likely has a stable income and access to healthcare, which is essential for prenatal and postpartum care. However, despite having a stable job, economic pressures can still exist, especially with the added financial burden of a new child.
Cultural Influences: Hispanic culture strongly emphasizes family values and support systems, often involving extended family in caregiving roles (Molina et al., 2019). This cultural trait might significantly affect her postpartum recovery and childcare strategies.
Healthcare Access and Utilization: Her access to and utilization of healthcare might be influenced by her cultural beliefs about childbirth and postpartum care and socioeconomic status. Hispanic women may experience barriers to healthcare due to language, cultural differences, and sometimes immigration status, even though they are employed in a legal capacity, which might mitigate some of these barriers (Escobedo et al., 2023).
Psychosocial Concerns
Anxiety as a First-Time Mother: The transition to motherhood is a significant life event that can trigger anxiety. Concerns about baby care, expectations of maternal role, and fear of inadequacy are common among first-time mothers (Need citation).
Social Isolation: Even with a supportive husband, the woman may experience feelings of isolation, mainly if extended family is not nearby or if her professional commitments limit her social interactions (Need citation).
Work-Life Balance: Returning to work and balancing professional responsibilities with new motherhood can lead to stress and potential strain on her mental health (Need citation).
This detailed breakdown offers a comprehensive view of the socioeconomic, cultural, and psychosocial factors affecting a Hispanic first-time mother working as a legal secretary.
References
Escobedo, L. E., Cervantes, L., & Havranek, E. (2023). Barriers in Healthcare for Latinx Patients with Limited English Proficiency-a Narrative Review. Journal of General Internal Medicine, 38(5), 1264–1271. https://doi.org/10.1007/s11606-022-07995-3
Molina, Y., Henderson, V., Ornelas, I. J., Scheel, J. R., Bishop, S., Doty, S. L., Patrick, D. L., Beresford, S. A. A., & Coronado, G. D. (2019). Understanding Complex Roles of Family for Latina Health: Evaluating Family Obligation Stress. Family & Community Health, 42(4), 254–260. https://doi.org/10.1097/FCH.0000000000000232

Examples: Prioritization of hypotheses (Analyze)Prioritization of Hypotheses (Analyze)
I included the rationale and the correlated cues but you do not need to include.
List the Hypothesis and the framework used to identify the order of priority.
Example:
Prioritize Hypothesis
Based on the cues from your patient establish priority hypotheses. Include the Framework
Here is an example of four priorities of care, along with the framework used to establish the priority order:
Fluid Volume Deficit Related to Postpartum Hemorrhage
Recognize Cues: RBC 3.12 , HGB 9.1 , Hct 27.1 , trace edema
Framework: ABC’s (Circulation)
Rationale: The patient’s low RBC, hemoglobin, and hematocrit levels suggest blood loss and anemia, potentially related to postpartum hemorrhage or surgery. While she shows trace edema, which might indicate fluid retention, the underlying issue of blood loss needs to be addressed to prevent hypovolemia or shock.
Priority: High (loss of blood volume impacts circulation and can be life-threatening if untreated).
Risk for Infection
Recognize Cues: Hepatitis C positive, HSV positive, elevated WBC 18.3, incisional tenderness
Framework: Safety/ABC’s (Airway, Breathing, Circulation)
Rationale: Infection control is critical for a postpartum patient with recent surgery (C-section). Elevated WBC suggests a potential for infection, and tenderness at the incision site could indicate infection risk. Hepatitis C and HSV also raise concerns for potential transmission and complications for both mother and infant.
Priority: High (due to the risk of sepsis or other systemic infections impacting circulation and systemic function).
Acute Pain
Recognize Cues: Pain 7/10 , incisional tenderness, unilateral breast engorgement, unilateral nipple bruising
Framework: Maslow’s Hierarchy of Needs (Physiological Needs)
Rationale: Pain control is essential for recovery and maintaining function. Severe pain can impair mobility, breastfeeding, and recovery from surgery. Addressing pain is a physiological need to promote healing and participation in care activities.
Priority: High (pain management will directly affect the patient’s ability to heal and care for herself and her infant).
Impaired Breastfeeding
Recognize Cues: Unilateral nipple bruising, unilateral breast engorgement, limited infant interaction/exposure before birth, limited PNC at 21 weeks
Framework: Maslow’s Hierarchy of Needs (Physiological/Belonging Needs)
Rationale: Successful breastfeeding is crucial for the newborn’s nutrition and bonding. The patient is experiencing physical challenges (bruising, engorgement), which may lead to poor breastfeeding practices. Limited prenatal care and minimal prior infant interaction indicate a need for education and support.
Priority: Moderate-High (physiological need for nutrition and bonding between mother and infant).
Frameworks Used:
ABC (Airway, Breathing, Circulation):
This is used to prioritize infection and fluid volume deficit, as these issues have immediate implications for circulation and potentially life-threatening outcomes.
Maslow’s Hierarchy of Needs:
Applied to acute pain and impaired breastfeeding, pain management and breastfeeding are critical physiological needs (the foundation of Maslow’s pyramid), as well as emotional and bonding aspects higher up the hierarchy.
Safety:

 

Infection prevention is a priority as a safety issue, considering potential complications that could impact both the mother and newborn.
By addressing these four key priorities—risk for infection, pain management, breastfeeding challenges, and fluid volume deficit—the nursing team can ensure holistic and effective care that supports the patient’s physical and emotional recovery.

Last Completed Projects