COLLEGE OF NURSING

Silliman University
Dumaguete City

PSYCHOLOGICAL ADAPTATIONS IN POSTPARTUM: NURSING CARE PLAN

Submitted by:
Quiber, Dominic S.
Pileo, Kristine Jamille R.

Submitted to:
Dr. Maria Theresa C. Belciña Jr.
 CASE SCENARIO
Lexie is an 18-year-old first time mother who just delivered her baby 2 weeks ago. Her mother died when she was still 3 years old and so she was raised by her
father until then. She happens to be a delinquent high school student at Judyville High School. Due to lack of guidance from her father, she engages to premarital
sex with her boyfriend, Jake. When they found out that she was pregnant, Jake broke up with her because he was not ready and this left her devastated and broken.
Now that her baby is here, Lexie is feeling down and begins to cry over little things. Her father has not paid her a visit ever since which made her even more
frustrated. She is trying to breastfeed but she is having a difficult time with this and feels discouraged. She just feels exhausted all the time and has become
increasingly nervous and fears that she will have to stop breastfeeding. She wonders if this is normal.

NURSING CARE PLAN

NURSING
CUES/EVIDENCES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Subjective Data: Anxiety related to lack Within our care, client Independent: At the end of our care,
of knowledge about will be able to manage the client has:
Client verbalized that child rearing anxiety as evidenced by: Establish a therapeutic Therapeutic interpersonal
she is not ready and is relationship, conveying relationships are the 1. Maintained vital
finding a hard time 1. Vital signs empathy and primary component of all signs within
assuming her new role within normal unconditional positive health care interactions that normal range
as a mother. range regard. facilitate the development
of positive clinician– 2. Appeared relax
Client also verbalized 2. Appear relaxed patient experiences. and reported
that she is regretful of and report that anxiety to a
the unfortunate event. anxiety is Be available to client for Offering self and showing tolerable level
reduced to a listening and talking. interest to client’s concerns
Objective Data: manageable level will make them open up 3. Verbalized
more. awareness and
V/S: 3. Verbalize expressed
T – 37.5 C awareness of Actively listen and Active listening builds feelings of
P – 90 bpm feelings of identify client’s strong relationships to anxiety.
R – 23 cpm anxiety perceptions of current client and helps to pay “Nakulba-an
BP – 120/80 mmHg situation. more attention to client’s lang ko kay
4. Identify healthy needs and feelings. daghan pa kong
Rattles when the baby ways to deal with wala na hibal-an
cries and express Review It represents an essential kabahin ni-ining
anxiety familial/physiological component of a patient’s akong pagka
Trembles and hand factors, current medical history, typically inahan.” As
tremors noted 5. Demonstrate prescribed medications, obtained at the time of verbalized
problem-solving and recent drug history. admission to a health care
Profuse sweating noted skills facility as one component 4. Identified ways
of a comprehensive patient to deal with and
Restlessness noted 6. Use assessment. express anxiety
resources/support by talking to her
Poor eye contact systems Monitor physical Ongoing anxiety is harmful support systems
observed effectively responses (e.g. when it becomes so or significant
palpitations/rapid pulse, irrational that you can’t others.
Appears to be confused repetitive movements, focus on reality or think
pacing). clearly. People with high 5. Showed a
No significant others anxiety have difficulty positive attitude
present shaking their worries. when dealing a
When that happens, they problem.
may experience actual
physical symptoms. 6. Communicated
with her parent/
Observe behavior To assess client’s coping relative to seek
indicative of level of abilities and evaluate her guidance and
anxiety. ability to understand support in
 present situation. dealing the
current situation.
Review coping skills To determine those that
used in the past. might be helpful in current
circumstances.

Subjective Data: Ineffective coping Within our care, client Independent: At the end of our care,
related to maturational will be able to cope the client has:
Client verbalized that transitions in response to positively as evidenced Establish therapeutic Client may feel free in the
she feels down at times stressors associated with by: nurse-client relationship. context of this relationship 1. Maintained vital
and cries over little child rearing to verbalize feelings of signs within
things. 1. Vital signs helplessness/powerlessness normal range
within normal and to discuss changes that
Client also verbalized range may be necessary in the 2. Showed
that she feels exhausted client’s life. appropriate range
all the time. 2. Display of feelings and
appropriate range Assess presence of When a client has coping felt less fear by
Objective Data: of feelings and coping skills/inner skills that have been calmly attending
lessened fear strengths. successful in the past, they the needs of the
V/S: may be used in the current newborn.
T – 37.5 C 3. Absence of facial situation to relieve tension
P – 90 bpm tension and and preserve the client’s 3. Displayed
R – 23 cpm improved sense of control. absence of facial
BP – 120/80 mmHg attention span tension and
Encourage client to talk Provide clues to assist improved
Appears to be frightened 4. Verbalize about what is happening client to develop positive attention span
and startles when the feelings with the at this time. coping behaviors.
baby starts to cry significant others 4. Expressed
and/or health Evaluate ability to Assist in identification and feelings with the
Facial tension and care provider understand events. correction of perception of significant other
grimacing observed throughout the Correct misperceptions reality and enables and health care
postpartum and provide factual problem-solving to begin. provider by
Appears preoccupied period information. sharing her
and quiet concerns about
Note expressions of Crisis situation may evoke the child rearing.
Impaired attention noted inability to find meaning questioning of spiritual
in life/reason for living, beliefs, affecting ability to
feelings of futility or cope with current situation
alienation from God. and plan for the future.

Promote a safe and May be helpful while

hopeful environment for client regains inner
the client. Identify control. The ability to
positive aspects of this learn from the current
experience and assist situation can provide skills
client to view it as a for moving forward.
learning opportunity.

Discuss the realities of This is a good way to help

parenting and the fact the woman develop
that it may be perspective and accept her
exhausting. new role as a mother.

Emphasize the need for Frequent contact with

continued partner and/or significant
 communication with the others keeps away feelings
partner and/or of isolation.
significant others who
are available to provide
support when loneliness
or anxiety becomes a
problem.

Collaborative: Additional assistance may

Refer to other resources be needed to help client
as necessary (e.g. clergy, resolve problems/make
psychiatrist, decisions.
family/marital therapist).

Subjective Data: Impaired adjustment Within our care, client Independent: At the end of our care,
related to low state of will show signs of the client has:
Client verbalized, optimism and lack of adjustment as evidenced Perform physical and/or To determine the extent of
“naglisod jud ko ug support system by: psychosocial the limitations of the 1. Maintained vital
adjust aning kahimtanga, assessment. current condition. signs within
makawala man ug gana 1. Vital signs normal range
uy.” within normal Listen to client’s Active listening builds
range perception of strong relationships to 2. Showed interest
Objective Data: inability/reluctance to client and helps to pay and participation
2. Demonstrate adapt to situations that more attention to client’s in assuming her
V/S: increasing are occurring currently. needs and feelings. new role
T – 37.5 C interest/participat
P – 90 bpm ion in parenting Review previous life To determine coping skills 3. Displayed
R – 23 cpm role situations and role used. absence of facial
BP – 120/80 mmHg changes with client. tension and
3. Develop ability improved
Neglects the baby when to assume Use therapeutic Nurses use curative attention span
she cries responsibility in communication skills. communication skills to
taking care of her provide new information, 4. Expressed
Exhibit poor eye contact baby accurate misinformation, feelings with the
encourage understanding significant other
Facial tension and 4. Identify stress of patient’s responses to and health care
grimacing observed situations leading health troubles, explore provider
to impaired choices for care, help in
Appears preoccupied adjustment and choice making, and
specific actions facilitate patient wellbeing.
Impaired attention noted for dealing with
them Acknowledge client’s Lessens feeling of
Absence of significant effort to adjust. blame/guilt and defensive
others 5. Identify the use response.
of appropriate
support system