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Client Initials: TH
Type of Delivery: Scheduled Cesarean Section
Client history and assessment:
TH is a 34 year old female scheduled for a repeat cesarean
section on 09/15/2009. The patient is a G3 P3, with both other
children delivered by C-section, with the only complication in both
being low birth weights. TH has a longstanding history of anorexia and
OCD AEB multiple notes in the chart not to discuss weight during
measurements obtained prior to MD exam in prenatal appointments,
and lack of desire to gain weight during pregnancy despite knowledge
of detrimental consequences to fetus. Additional health history
includes a vitamin D deficiency, back surgery in 05/06 due to a
herniated disc, and two previous cesarean sections.
TH delivered a healthy baby boy weighing 6 lb. 2 ounces, with
apgar scores of 8 and 9; the patient did well through delivery and
during the postoperative stage. No lack of sensation or motor function
following discontinuation of epidural anesthesia was noted. The two
previous infants delivered without extreme difficulty, with the first born
via c-section d/t fetal distress. Throughout the procedure and
throughout the recovery stage, the patient had the positive support of
husband. The incision site was clean with steri-strips covering, but
without any signs of infection (no redness, swelling, drainage, or
edema noted).
The patient has no difficulties with breastfeeding, but a lack of
nutrition was a possibility of great concern. The two previous infants
were breast-fed by the patient, without any difficulty. TH was hesitant
towards talking about food in general, and was seen to only eat 25% -
50% of the small amounts of food ordered.

Diagnosis #1: Infection, Risk for r/t site for microorganism
invasion 2O cesarean section.
Assessment Data: (please see client history and assessment for more
information) with a history of malnutrition and an incision site, the
increased possibility of infection needs to be take into account.
Goals (measurable): The patient will not experience signs of infection
by discharge.
Interventions Rationale Outcome

Wash hands before Interventions help Goal Met: Patients
and after caring for prevent the spread of remains free from
patient, using gloves pathogens between symptoms of
when indicated; no staff and patients. infection by
sharing of equipment discharge.

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with other units.
Assess lower Assessment provides Goal Met: Incision is
abdominal incision information about dry and intact,
noting if area under developing infection: edges well-
and around steri-strips Local inflammatory approximated,
is clean, dry and effects cause redness without redness or
intact, if incisions and edema. This may edema through to
exhibit redness, be followed by purulent discharge.
edema, ecchymosis, drainage and would
drainage, and dehiscence.
Assess temperature Fever may be the first Goal Met: Patient
Q4 hours orally. sign of infection in the without temperature
obstetrics patient, and >38.5oC in a single
temperature values can measurement, or
have important three temperatures
consequences for of >38o C by
treatment decisions. discharge.
Maintain a clean A clean environment Goal Met: Linens
environment. Ensure may discourage the separated r/t dirty
the client’s room and growth of and clean in
bathroom is cleaned microorganisms. restroom, personal
frequently and care supplies kept
appropriately. off floor, bed linens
changed Qday or
PRN through to

Diagnosis #2: Nutrition, imbalanced: less than body
requirements r/t inability to ingest/digest food or absorb
nutrients because of psychological factors AEB aversion to
eating, lack of interest in food, distorted verbalizations of body
Assessment Data: (please see client history and assessment for more
information) TH was offered assistance on multiple occasions
throughout care to order food without any peak of interest. The
patient has a history of anorexia with a history of decreased weight in
previous deliveries due to a lack of weight gain during pregnancy, and
a heightened interest in pounds gained throughout pregnancy. During
examination of patient, and abdominal assessment, patient voiced
feelings of obesity, and discontent for appearance, apologizing for her
large size.
Goals: The patient will recognize three factors contributing to
underweight and will remain free of signs of malnutrition by discharge.
Interventions Rationale Outcome evaluation

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Maintain a high Impaired immunity Goal Met: Through a high
index of suspicion is a critical adjunct index of suspicion of
of malnutrition as in malnutrition- malnutrition, staff assisting
a contributing associated patient were able to
factor in infections in all age implement interventions to
infections. groups in all decrease additional risk
populations. contributing to infection risk.
The patient remained free of
any signs or symptoms of
infection by discharge.
Observe patient’s It may be difficult to Goal Met: Patient interacted
relationship to tell if the problem is with during mealtimes
food. Attempt to physical or throughout the day without
separate physical psychological. any interest in food at
from Refusing to eat may bedside unless the topic of
psychological be the only way the consumption was brought
causes for eating patient can express up. Through observation it
difficulty. some control, and it was noticeable the cause for
may also be a difficulty with eating was
symptom of psychological, with only
depression. minimal amount consumed
by end of shift.
Provide Mealtime usually is Goal Met: Companionship
companionship at a time for social provided by various staff
mealtime to interaction; often members during mealtimes
encourage patients will eat to encourage nutritional
nutritional intake. more food if other intake with patients
people are present consuming improved
at mealtimes. amounts by discharge.
Establish trusting Establishment of Goal Met: establishment of
relationship with trust promotes a trusting relationship with
patient. Spend sense of safety and patient developed through
time with patient, support for the spending time with patient
provide for patient. with times provided for
privacy, and mother/baby privacy while
remain remaining nonjudgmental
nonjudgmental. throughout care to
discharge. This trusting
relationship allowed the
patient feelings of support
and safety, eliciting a
decrease in stress and an
increase in appetite due to
strengthened emotional
Assist patient to Exercise, Goal Met: Assisted patient in

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identify healthy meditation, and identification of healthy
behaviors she can relaxation behaviors which could be
use to reduce techniques help to useful in the reduction of
unavoidable relieve stress and unfavorable stressors which
stresses (i.e. improve health. could increase anxiety and
exercise, depression causing a
meditation, decrease in appetite or
relaxation desire to eat. Due to
techniques, etc.) interventions provided, the
patient was able to verbalize
various activities to assist
her in stress reduction by
Encourage patient Patient may have Goal Not Met: The
to seek and unrealistically high intervention was attempted
accept social expectations for to be provided as a tool to
support with herself, or may increase the patients
nutrition and need “permission” understanding of anorexia,
psychosocial to ask for help. and assist her in the
difficulties during eventual recovery process –
the puerperium. but the patient will very
reluctant to acknowledge a
problem, but with continued
implementation of this
intervention by various staff
members it is possible to
meet this goal by discharge.

Diagnosis #3: Breast-Feeding, Effective r/t maternal-infant
dyad satisfaction and success with breast-feeding process AEB
patients report of satisfaction with breast-feeding process,
and exhibits of the infant regularly sucking and swallowing
(appears content after feeding).
Assessment Data: (please see client history and assessment for more
information) When questioned regarding satisfaction with the breast-
feeding status of the newborn, the patient responded that she enjoyed
the experience to bond with her child, and the infant latched on within
the first two hours following delivery.
Goals: Maternal-infant dyad continues to experience effective breast-
feeding by day 3 following delivery, with reevaluation two weeks
following delivery.

Interventions Rationale Outcome evaluation

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Assess patient’s Assessment Goal Met: Assessment
previous experiences, provides of the patient’s previous
knowledge, and skill information about experience, knowledge
(positioning, latch-on, knowledge and and skill with breast-
removal, etc.) with skills. The patient feeding illustrates
breast-feeding. Elicit may benefit from sufficient understanding
questions or concerns. current research with ample time for
Share current research findings. questions or concerns
findings as provided by discharge.
Facilitate patient’s Interventions Goal Met: Samples of
breast-feeding by not promote infant’s formula upon discharge
offering supplements interest in nursing not offered,
to the infant, and allow frequent encouragement of
promoting rooming-in, stimulation of the rooming-in, and
etc. as the patient breasts. breastfeeding on
desires. demand allowed the
mother and infant
facilitation of continued
effective breast-feeding
until discharge, without
problem upon
Praise patient and Praise reinforces Goal Met: Provided
infant for effective effective breast- patient and infant praise
breast-feeding feeding. Maternal for effective breast-
activity. confidence is an feeding activity with
important factor in evident increase in
the continuation of maternal confidence
breastfeeding,. during praise, with
continued growth of
assurance upon
Assess support person Social support is an Goal Met: Support
network. important factor in person, husband to TH
the choice of and father to infant and
breastfeeding and patient’s other two
its success. The children, assessed with
more affirmation a importance given to
mother receives alleviation of
from members of misconceptions and
her social network social embarrassment
the better she associated with breast-
copes with feeding to given father

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breastfeeding. encouragement for
support by discharge.
Provide patient with Written instruction Goal Met: Patient
written and verbal allows patient to provided with simple
information about review material written but
daily nutrient and once she is individualized verbal
caloric needs during discharged, and information about daily
lactation: PNV, 4 individual nutrient and caloric
servings protein, 5 instruction needs during lactation,
servings dairy (1 quart promotes with suggestions
milk), 2-3 servings compliance. regarding continued
fruit (2 vitamin C-rich), compliance in relation to
2-3 servings increased newborn well-
vegetables (1+ green being by discharge.
leafy), 2-3 quarts
Teach the patient the Dieting during Goal Met: The
importance of lactation can have a importance of maternal
maternal nutrition. negative impact on nutrition during
milk production. lactation explained to
the patient, with
emphasis on lack of
necessary milk nutrients
and production provided
to the infant, with
patient’s verbalization
of understanding prior
to discharge.
Review guidelines for In the first few Goal Met: Frequency of
frequency of feedings days, frequent and feeding guidelines
(Q 2 – 3 hours, or at regular stimulation reviewed with patient,
least 8 feedings per 24 of the breasts is with importance of
hours). important to frequent and regular
establish an breastfeeding to
adequate milk promote the
supply. establishment of an
adequate supply of milk,
with patient
demonstrating and
voicing understanding
prior to discharge.

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