Professional Documents
Culture Documents
VB: Report from labor nurse if applicable CB: Report from OR recovery nurse
Assessments
VB: Postpartum assessments q30 min 2, q1h 2, then q4h. Includes Fundus firm, midline, at or below umbilicus Lochia rubra 1 pad/hr; no free flow or passage of clots with massage Bladder: voids large amounts of urine spontaneously; bladder not palpable following voiding Perineum: sutures intact; no bulging or marked swelling; no c/o severe pain. Minimal bruising may be present. If hemorrhoids present, no tenseness or marked engorgement; 2 cm diameter Breasts: soft, colostrum present Vital Signs: BP WNL: no hypotension; not 30 mm Hg systolic or 15 mm Hg diastolic over baseline Temperature: 38 C (100.4 F) Pulse: bradycardia normal, consistent with baseline Respirations: 1220/min; quiet, easy Comfort level: 3 on scale of 110 CB: Postpartal cesarean assessment q 15min 4, q30min 4, q1h per protocol; all assessment parameters for VB included, as well as Surgical dressing over incision clean and dry or with minimal drainage Foley catheter in place, urine color and amount noted IV: no swelling, pain, or redness at insertion site; infusing at prescribed rate Bowel sounds: present, decreased, or minimal LOC: alert and oriented, easily aroused if dozing LOS: sensation WNL for anesthesia or analgesia type administered Pulse ox: WNL Input and output: WNL
VB: Continue postpartum assessment q4h 2, then q8h Breast: evaluate nipple status; should be no evidence of cracks or bruising Observe feeding technique with newborn Vital signs assessment q8h; all WNL; report temperature 38 C (100.4 F) Assess Homans sign q8h Continue assessment of comfort level CB: Continue cesarean assessments per protocol, including all assessments covered in VB; as well as Determine if woman passing flatus Determine if bowel sounds present
Information is included for both vaginal birth (VB) and cesarean birth (CB). However, since many of the nursing care interventions are the same for either, specific interventions or suggestions related to vaginal birth are designated VB, and those specific to cesarean are designated CB. ADL, activities of daily living; BP, blood pressure; CB, cesarean birth; CNM, certified nurse-midwife; DC, discontinue; LDR, labor, delivery, and recovery; OOB, out of bed; OR, operating room; prn, as needed; VB, vaginal birth; WNL, within normal limits.
CLINICAL PATHWAY
Category Teaching/ psychosocial First 4 Hours
Explain postpartum assessments Teach self-massage of fundus and expected findings; rationale for fundal massage Instruct to call for assistance first time OOB and prn Demonstrate perineal care, surgigator, sitz bath prn Explain comfort measures Begin newborn teaching; bulb suctioning, positioning, feeding, diaper change, cord care Orient to room if transferred from LDR room Provide information on early postpartal period Assess mother-infant attachment CB: Teach turn-cough and deep breathing exercise Explain importance of moving around in bed and moving legs up and down Demonstrate splinting of abdomen for increased comfort with movement Discuss plan of care related to cesarean recovery; activity and ambulation recommendations, advancement of diet, incision care, schedule for IV and Foley catheter removal Provide information about PCA, pain medications, and alternate measures for pain management
VB: Ice pack to perineum to decrease swelling and increase comfort Straight catheter prn 1 if distended or voiding small amounts If continues unable to void or only voids small amounts, insert Foley catheter and notify CNM or physician CB: Implement input and output regimen Maintain IV as ordered Medicate for pain Begin providing ice chips when bowel sounds are present
Sitz baths prn If woman Rh negative and infant Rh positive, Rh immune globulin workup; obtain consent; complete teaching Determine rubella status Obtain consent for rubella vaccine if indicated; explain purpose, procedure, implications of vaccine CB: Advance diet as ordered and tolerated Assist with perineal care and ADLs Obtain hematocrit and hemaglobin Discontinue Foley catheter when woman can ambulate to BR Discontinue of heplock IV when woman can tolerate oral fluids, or as ordered Maintain incision care as ordered
Continue sitz baths prn May shower if ambulating without difficulty DC buffalo cap (heparin lock) if present Administer rubella vaccine as indicated Expected Outcomes Using sitz bath; voids qs; lab work WNL; performs ADL without sequelae
Activity
VB: Assistance when OOB first time, then prn Ambulate ad lib Rests comfortably between assessments CB: Assistance with movement in bed, to include leg exercises and sitting upright
Encourage rest periods Ambulate ad lib; may leave birthing unit after notifying staff of plan to ambulate off unit CB: Advance movement to include hanging legs over edge of bed and brief standing
Up ad lib CB: Assist woman to ambulate as soon as possible Expected Outcomes Ambulates ad lib
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CLINICAL PATHWAY
Category Comfort First 4 Hours
Institute comfort measures: Perineal discomfort: peri-care; sitz baths, topical analgesics Hemorrhoids: sitz baths, topical analgesics, digital replacement of external hemorrhoids; side-lying or prone position Afterpains: prone with small pillow under abdomen; warm shower or sitz baths; ambulation Administer pain medication _____ CB: Implement PCA or pain medication schedule as ordered
Nutrition
VB: Regular diet Fluid 2,000 mL/day CB: Begin sips and chips when bowel sound present or per protocol
Continue diet and fluids CB: Advance diet to clear liquids as tolerated or per protocol
Continue diet and fluids CB: Advance diet as tolerated Expected Outcomes Regular diet/fluids tolerated Same Expected Outcomes Voiding qs; passing flatus or bowel movement Continue medications RhoGAM and rubella vaccine administered if indicated Expected Outcomes Vaccines administered; pain controlled Review discharge instruction sheet/checklist Describe postpartum warning signs and when to call CNM or physician Provide prescriptions; gift packs given appropriate for bottle- or breastfeeding Arrangements for baby pictures as desired Postpartum and newborn visits scheduled Expected Outcomes Discharged home; mother verbalizes postpartum warning s/s, follow-up appointment times and dates
Elimination
Voiding large amounts straw-colored urine CB: A minimum of 30 cc qh clear urine output in Foley catheter
Voiding large quantities May have bowel movement CB: A minimum of 30 cc qh clear urine output in Foley catheter Continue meds Lanolin to nipples prn; tea bags to nipples if tender; heparin flush to buffalo cap/heplock (if present) q8h or as ordered May take own prenatal vitamins Discuss typical newborn schedule; plan for periods of rest Birth certificate paperwork completed Evaluate plans for transporting newborn; car seat available CB: Evaluate for physical help at home
Medications
Pain medications as ordered Methergine 0.2 mg q4h po if ordered Stool softener _______ Tucks pad prn, perineal analgesic spray
Evaluate knowledge of normal postpartum and newborn care Evaluate support systems
Family involvement
Identify available support persons Assess family perceptions of birth experience Parenting: demonstrates culturally expected early parenting behaviors
Involve support persons in care, teaching; answer questions Evidence of parental bonding behaviors present
Continue to involve support persons in teaching, involve siblings as appropriate. Plans made for providing support to mother following discharge Expected Outcomes Evidence of parental bonding behavior; support persons verbalize understanding of womans need for rest, good nutrition, fluids, and emotional support
Date