Oakton Community College
Student_______________________ Date________
Post Partum Care Plan
Clients Initials________ Age______ Martial Status ________ Religion _________ Culture __________
Prenatal Classes_____ Support Person _____________ Pre-pregnancy Wt ______ Present Wt _______
EDC_____________ Gravida______ Para_____ LC______ Gestation by dates___________
Type of Delivery ___________ Date of Birth _______Time_______ Sex of baby______
Weight _____________ Length _____________ APGARS ______ Baby Blood Type __________
Allergies ____________________
History: List any significant history of current pregnancy either prior to or during pregnancy (prenatal):
Current Medications, illnesses, previous surgeries, exposure to communicable diseases, problems
or concerns, amount of weight gain.
Describe past obstetrical history in terms of year of birth, gestation, length of labor, and any
problems during pregnancy or post partum
Prenatal Labs : Blood Type & Rh of mother____________ Rubella Titer ________ Hepatitis B ______
Describe history of current delivery (onset of contractions, rupture of membranes, induction or augmentation of labor, anesthesia - IV/IM meds, local, epidural, paracervical block, pudendal, -how long in labor, pushing, after birth, etc.)
Medications: Name, Dose, Route, Frequency, Action, Side Effects
Physical Assessment
Describe findings for Activity/Exercise: Vital Signs, Fundus, Episiotomy, Pad saturation, Lochia, Edema, Homan’s Sign, and Lung sounds Include any interventions such as ice pack to perineum.
Lab findings – Hgb and Hct, and work-up if Rh negative.
Describe findings for Nutrition/Metabolism: Skin turgor, mucus membranes, diet, IV fluids, current appetite, formula feeding or breast feeding. Include any interventions you performed.
Describe findings for Elimination: Bowel sounds, hemorrhoids, perineal swelling/laceration, amount voided since delivery, hours since delivery, frequency of urination, catheterized during hospitalization, history of UTI. Include any interventions you performed.
Describe findings for Cognitive/Perceptual: pain in terms of episiotomy, contraction of uterus, breast, etc. Headaches, numbness, tingling, LOC, cranial nerve assessment, coordination, sensation, activity
Behavior in terms of calm, cooperative, anxious. Include any interventions you performed.
Health Management/Health Perception: Describe findings of general health perception, changes in her life to protect her baby, and important measures doing for family safety.
Self Perception/Self Concept: Identify and describe findings for Erickson’s Stage of Development, education, occupation, and indications of creativity and problem solving ability.
Coping and Stress Tolerance: Describe reaction to pregnancy and birth of baby, activities that have worked in the past to help cope and relieve stress, the most difficult change anticipated with the arrival of the new baby, anticipated sleep patterns changes with the new baby, activities done for relaxation, and plans for rest when discharged.
Role/Relationship: Describe family members, primary care giver, shopping, cooking, laundry. Pets. Perception of changes to family relationship
Values/Beliefs: Describe client’s primary language. Cultural traditions want to pass on to child. Religious traditions want child to continue.
Describe Client’s Response to infant:
Describe Clients Knowledge of: breast care, involution, elimination, Infant Care, Medications
Include goals
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