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N3731 Course Packet 1

Student’s Name: Paige Bandera Date of Care: 3-15-17

YOUNGSTOWN STATE UNIVERSITY


N3731: Childbearing Family and Women’s Health Nursing

POSTPARTUM HEALTH ASSESSMENT

Client’s Initials S.M. Age 31 LMP July 2016 EDD 3/17/17 Marital Status Married

Gravida 6_;T 3 P 0 A 2 L 3

Delivery Date: 3-15-17 Time: 1002 Postpartum Day: 1

Blood Type / Rh: O/ + RhoGAM: YES / NO Breast or Bottle Feeding (Circle)

If applicable, describe how labor was augmented or induced: C-section (primary) baby was transverse to

breech footling.

Type of Delivery: C-section

Episiotomy: Type N/A Lacerations N/A

Boy / Girl – Birth Weight: 7 lbs 10.6 oz. Length: 50.75 cm APGAR: 7/9

Was pregnancy: Planned / Unplanned? Was birth control used? Yes / No

Type or method of birth control, if used: N/A

Prenatal Care: YES / NO Number of Prenatal Visits: 7

Significant antepartal, intrapartal, or postpartum history: Car accident at 35 weeks gestation. Pt thrown

into ditch, blackened eyes bilaterally. No police report filed.

Significant maternal medical history: No significant maternal medical history.

Current Health Status: Stable and A&Ox3

Did she attend childbirth education classes? YES / NO


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NURSING DIANOSES
PYSICAL ASSESSMENT
(PRIORITIZE)
VITAL SIGNS
Temp 98.6 F Pulse 84 Resp 20 BP 125/68

2) Risk for bleeding: Risk


OBSTETRICAL
factors: C-section and
Breasts Frim, soft, nontender. Pt does not complain of pain. postpartum complications.
Fundus Firm; 1 fb above umbilicus.
Lochia Moderate rubra with no clots. 1) Acute pain r/t postpartum
changes and surgical incision
Perineum Intact. Pt had C-section.
aeb verbal report from pt.
(Rated pain as 7 on 0-10 scale)
SKIN / FLUIDS
Skin: Dry / Cool / Clammy / Diaphoretic 3) Impaired skin integrity r/t C-
section aeb incision.
Color: Consistent with genetic background /
Pale / Flushed / Cyanotic / Jaundiced
Turgor: Good / Fair / Poor Diaphoresis: YES / NO

8)Fatigue r/t childbirth, new


PERIPHERAL – NEUROLOGICAL
responsibilities of parenting,
LOC: Alert / Lethargic / Disoriented body changes.
Upper Extremities:
7) Risk for activity intolerance:
Movement Active; Full ROM (+5) in UE. Risk factors: exertional
discomfort, verbal report of
Strength Able to maintain flexion against resistance.
fatigue, verbal report of
Sensation Full sensation in UE. weakness.
Lower Extremities:
Movement Active; Full ROM (+5) in LE.
Strength Able to maintain flexion against resistance.
Sensation Full sensation in LE.
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NURSING DIANOSES
CARDIOVASCULAR
(PRIORITIZE)
Apical: Regular / Irregular Rate 84 6) Risk for imbalanced fluid
volume: Risk factors: shift in
Pulses: Radial: R +2 L+2 Pedal: R +2 L +2
blood volume, edema.
Edema: Location / degree Generalized edema of Upper and
lower extremities. Non-pitting.
Varicosities: None.
Capillary Refill: < 3 seconds.

12) Readiness for enhanced


RESPIRATORY / OXYGENATION
family processes aeb no longer
History of shortness of breath, smoking, allergies: Pt quit smoking to ensure a healthy
pregnancy.
smoking 7 months ago. NKA.
Respirations: Easy / Labored
Dyspnea: With activity / At rest/ None
Cough: Non-productive / Productive/ No cough
Breath Sounds: Clear / Diminished: R / L
No adventitious sounds.
GASTROINTESTINAL / NUTRITION
5) Risk for constipation: Risk
Height: 162.5 cm Weight:150 lbs. to 190 lbs. Factors: hormonal effects on
smooth muscles, fear of
Pregnancy weight gain: 40 lbs.
staining with defecation, effects
Usual nutritional intake from Basic Food Groups: (give of anesthesia.
examples) Pt states “I eat what I want, as much as I want
and when I want.” Pt eats more than 3x a day and keeps
a standard American diet consisting of all food groups.
Intake of alcohol, tobacco, caffeine, street drugs:
Quit smoking 7 months ago. Denies caffeine, alcohol or use
of street drugs. Positive for THC (2-13-17).
Adequate nutritional intake for breast feeding, tissue repair:
Yes, pt has an adequate appetite. Observed pt eating
Taco Bell and dinner from cafeteria.
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NURSING DIANOSES
Abdomen: Soft / Firm / Distended / Tender
(PRIORITIZE)
Bowel Sounds: Normoactive / Hypo / Hyper / Nausea / Vomiting
Bowel Movement since Delivery: No
GENITOURINARY 4) Risk for altered patterns of
urinary elimination r/t effects
Urine output: 1,250 ml of clear urine via Foley catheter.
of anesthesia.
Difficulty voiding since delivery Catheter removed at 1900
pt voided without difficulty.
SLEEP / COMFORT 9)Sleep Pattern Disturbance
r/t excitement, discomfort and
Sleep pattern: Pt is not well rested r/t to responsibilities of a
environmental interruptions
mother. aeb verbal report of tiredness.
Feel rested in AM? No Naps? No
Usual methods of coping with pain/discomfort:
Pt reports “suck[ing] it up”.

PSYCHOSOCIAL HEALTH ASSESSMENT


Social Interactions:
Maternal-newborn attachment: Pt is enamored with new
baby.
Relationship/interaction with her other children: Pt is very
fond of her other children.
Relationship/interaction with father of newborn:
Pt reports a “good relationship”. Husband seemed distant
and critical of pt.
Support system: Husband
Any changes in family relationships, support
system, home/work environment in the past year?
No changes in family, support system or home/
work environment.
Interests/hobbies: Netflix, movies, housework and childcare.
NURSING DIANOSES
Spirituality: Member of an organized religion?
(PRIORITIZE)
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No spirituality or organized religion.


How important is her religion/spirituality to her?
N/A
Sense of Self:
Ethnic and cultural background: Caucasian; various
11) Risk for spiritual distress:
cultural backgrounds. Risk Factors: life changes,
poor relationships, stress.
How does her ethnic/cultural background influence health
behaviors?_ Pt engages in standard American behaviors.
Occupation or previous employment history: Unemployed
homemaker.

DEVELOPMENTAL HEALTH ASSESMENT


(Refer to article by Ramona Mercer)
What is this mother’s stage of growth and
development which you identified from your
assessment data? (include data to support your
conclusions): The patient is at the second stage “acquaintance
with and increasing attachment to the
infant, learning how to care for the infant and physical
restoration” (Mercer, 2005, p. 649) as evidenced by being
one day postpartum. Some data that supports she is one
day postpartum is that her fundus is 1 fb above her
umbilicus, her lochia is moderate/rubra and she is
diaphoretic.
Identify and define her expected stage of growth and
development? This mother is where I would expect her to be.
Which is in the second stage, as mentioned above.
The second stage is a time of recovery and bonding with the neonate. A
woman at her first postpartum day enters
the second stage regardless of mental readiness because
she has undergone the physical process of labor and a
newborn has been brought into the world.
NURSING DIANOSES
Has this mother successfully accomplished the
(PRIORITIZE)
developmental tasks of pregnancy (include assessment
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data)? At this stage she has accomplished the


developmental tasks of pregnancy as demonstrated by her
health seeking behaviors. She reports 7 prenatal checkups,
10) Risk for Caregiver Role
that she quit smoking and denies drug or alcohol use.
Strain: Risk Factors:
Despite, testing positive for THC, the aforementioned caregiver is female, care giver
is spouse, caregiver is
evidence suggests that S.M. took measures to prepare for the
isolated, amount of
birth of a healthy baby. caregiving tasks.

What does this mother think about her present


situation/circumstance? She seems to be taking it all in still.
She is very concerned about her post C-section pain and
Comments “ I can’t believe I have four kids now”.

How does this mother anticipate changes r/t herself


She anticipates being busier.
Changes R/T family dynamics: S.M. will continue to stay
at home and care for the children. However, she will have
one more child to care for and her husband will have one
more person to provide for.
What questions does this mother have at this time?
Pt denies having questions at this time.
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NURSING DIANOSES
What could you do to facilitate her growth and
(PRIORITIZE)
development? I need to build a rapport with S.M. so
that I can identify her specific needs. As a mother of
four she already knows a great deal; however, there is
always teaching that can be done. This is her first C-
section so post-operative teaching as it pertains to a
C-section may help S.M. grow.
What are the educational needs for this mother to
care for herself, her newborn, and family?
So far S.M. needs to be educated on Toradol as it is
a part of her pain management and self-care. Additionally,
she needs to be reeducated on breast-feeding techniques
in order to care for her newborn. She may also require
education on building a larger support system so that she
does not become overwhelmed with the job of being
a homemaker.
Social Support Services (if applicable)

None in use or identified at this time.


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Test Parameter Test Result Probable Cause Nursing Action


Done 11/14/16
Chlamydia Negative/ Negative N/A N/A
Positive
Gonorrhea Negative/ Negative N/A N/A
Positive
Toxicology Negative/ Negative N/A N/A
Positive

US N/A 22W1 N/A N/A


Done on 2/13/17
Blood Type ABO O N/A N/A
RH type +/- + N/A N/A
HCT 36-44% 30.6% physiologic “normal
anemia r/t adaptation”
pregnancy (Lowdermilk, p.
344)
Hgb 12-15 g/dL 10.1 g/dL physiologic “normal
anemia r/t adaptation”
pregnancy (Lowdermilk, p.
344)
Rubella Reactive/ Nonreactive N/A N/A
Nonreactive

VDRL Negative/ Negative N/A N/A


Positive

HBsAg Negative/ Negative N/A N/A


Positive

US N/A 35W1 N/A N/A

Group B Negative/ Negative N/A N/A


Streptococcus Positive

Toxicology N/A + THC Marijuana use Pt teaching on


risk avoidance

Done on 3/15/17
HCT 36-44% 30.5 % physiologic “normal
anemia r/t adaptation”
pregnancy (Lowdermilk, p.
344)
Hgb 12-15 g/dL 10.2 g/dL physiologic “normal
anemia r/t adaptation”
pregnancy (Lowdermilk, p.
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344)

Toxicology N/A Negative N/A N/A

MEDICATIONS: Include all Routine and PRN medications used during Labor, Delivery and
Postpartum. Describe type, amount, pharmacological actions, times of administration, reason for
administering the drug, and nursing actions. List here and attach Medication Sheets for each med.
1. Lovenox 40 mg sub daily to prevent blood clots
2. Toradol 30 mg IV push q 6 hours for 1 day to manage pain
3. Lactated Ringers 1,000 ml 75 ml/hr continuously for 13.3 hours to hydrate
4. Oxytocin IV additive 30 U in NaCl 0.9% 500 ml (40 ml/hr) continuously to contract uterus
5. Diphenhydramine 25 mg IV push 6 hours PRN for itching
6. Ibuprofen 600 mg q 8 hours PRN for mild pain of 1-3
7. Methylergonovine 0.2 mg IM PRN for hemorrhage
8. Nubian 5 mg IV push q 4 hours PRN for moderate breakthrough pain or itching
9. Naloxone 80 mcg IV push q 2 minutes PRN for opioid reversal
10. Ondansetron 4 mg IV push q 8 hr PRN for nausea and vomiting
11. Oxycodone-acetaminophen 2 tablets oral q 4 hours PRN for severe pain of 7-10 or 1 tablet for
moderate pain of 4-6
12. Oxygen therapy 1 liter via nasal cannula PRN

EVALUATION AND INDICATION OF STUDENT’S PROFESSIONAL GROWTH: The following


narrative should include but is not limited to: (1) Summary and evaluation of total care implemented for
mother and newborn, (2) what you would do differently, (3) what you would do for this expanding
family if you were the primary nurse form admission to discharge, (4) discharge planning, and (5) what
you learned from this family and from this clinical experience.

REFERENCES (APA) FORMAT ONLY (Must include OB text, do not use care plan books!)
N3731 Course Packet 10