with other units.Assess lowerabdominal incisionnoting if area underand around steri-stripsis clean, dry andintact, if incisionsexhibit redness,edema, ecchymosis,drainage, andapproximation.Assessment providesinformation aboutdeveloping infection:Local inflammatoryeffects cause rednessand edema. This maybe followed by purulentdrainage and woulddehiscence.Goal Met: Incision isdry and intact,edges well-approximated,without redness oredema through todischarge.Assess temperatureQ4 hours orally.Fever may be the firstsign of infection in theobstetrics patient, andtemperature values canhave importantconsequences fortreatment decisions.Goal Met: Patientwithout temperature>38.5
C in a singlemeasurement, orthree temperaturesof >38
C bydischarge.Maintain a cleanenvironment. Ensurethe client’s room andbathroom is cleanedfrequently andappropriately.A clean environmentmay discourage thegrowth of microorganisms.Goal Met: Linensseparated r/t dirtyand clean inrestroom, personalcare supplies keptoff floor, bed linenschanged Qday orPRN through todischarge.
Nutrition, imbalanced: less than bodyrequirements
inability to ingest/digest food or absorbnutrients because of psychological factors
aversion toeating, lack of interest in food, distorted verbalizations of bodyimage/size
Assessment Data: (
please see client history and assessment for moreinformation
) TH was offered assistance on multiple occasionsthroughout care to order food without any peak of interest. Thepatient has a history of anorexia with a history of decreased weight inprevious deliveries due to a lack of weight gain during pregnancy, anda heightened interest in pounds gained throughout pregnancy. Duringexamination of patient, and abdominal assessment, patient voicedfeelings of obesity, and discontent for appearance, apologizing for herlarge size.Goals: The patient will recognize three factors contributing tounderweight and will remain free of signs of malnutrition by discharge.