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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 evaluation Wash hands before and after caring for patient, using gloves when indicated; no sharing of equipment Jones 1 Interventions help prevent the spread of pathogens between staff and patients. Goal Met: Patients remains free from symptoms of infection by discharge.
with other units. Assess lower abdominal incision noting if area under and around steri-strips is clean, dry and intact, if incisions exhibit redness, edema, ecchymosis, drainage, and approximation. Assess temperature Q4 hours orally.
Assessment provides information about developing infection: Local inflammatory effects cause redness and edema. This may be followed by purulent drainage and would dehiscence. Fever may be the first sign of infection in the obstetrics patient, and temperature values can have important consequences for treatment decisions. A clean environment may discourage the growth of microorganisms.
Goal Met: Incision is dry and intact, edges wellapproximated, without redness or edema through to discharge.
Maintain a clean environment. Ensure the client’s room and bathroom is cleaned frequently and appropriately.
Goal Met: Patient without temperature >38.5oC in a single measurement, or three temperatures of >38o C by discharge. Goal Met: Linens separated r/t dirty and clean in restroom, personal care supplies kept off floor, bed linens changed Qday or PRN through to discharge.
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 image/size 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
Maintain a high index of suspicion of malnutrition as a contributing factor in infections.
Impaired immunity is a critical adjunct in malnutritionassociated infections in all age groups in all populations.
Observe patient’s relationship to food. Attempt to separate physical from psychological causes for eating difficulty.
Provide companionship at mealtime to encourage nutritional intake. Establish trusting relationship with patient. Spend time with patient, provide for privacy, and remain nonjudgmental.
Assist patient to Jones 3
Goal Met: Through a high index of suspicion of malnutrition, staff assisting patient were able to implement interventions to decrease additional risk contributing to infection risk. The patient remained free of any signs or symptoms of infection by discharge. It may be difficult to Goal Met: Patient interacted tell if the problem is with during mealtimes physical or throughout the day without psychological. any interest in food at Refusing to eat may bedside unless the topic of be the only way the consumption was brought patient can express up. Through observation it 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. Mealtime usually is Goal Met: Companionship a time for social provided by various staff interaction; often members during mealtimes patients will eat to encourage nutritional more food if other intake with patients people are present consuming improved at mealtimes. amounts by discharge. Establishment of Goal Met: establishment of trust promotes a trusting relationship with sense of safety and patient developed through support for the spending time with patient patient. with times provided for mother/baby privacy while remaining 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 support. Exercise, Goal Met: Assisted patient in
identify healthy behaviors she can use to reduce unavoidable stresses (i.e. exercise, meditation, relaxation techniques, etc.)
meditation, and relaxation techniques help to relieve stress and improve health.
Encourage patient to seek and accept social support with nutrition and psychosocial difficulties during the puerperium.
Patient may have unrealistically high expectations for herself, or may need “permission” to ask for help.
identification of healthy behaviors which could be useful in the reduction of unfavorable stressors which could increase anxiety and depression causing a decrease in appetite or desire to eat. Due to interventions provided, the patient was able to verbalize various activities to assist her in stress reduction by discharge. Goal Not Met: The intervention was attempted to be provided as a tool to increase the patients understanding of anorexia, and assist her in the eventual recovery process – 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 breastfeeding 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 breastfeeding by day 3 following delivery, with reevaluation two weeks following delivery.
Assess patient’s previous experiences, knowledge, and skill (positioning, latch-on, removal, etc.) with breast-feeding. Elicit questions or concerns. Share current research findings as appropriate. Facilitate patient’s breast-feeding by not offering supplements to the infant, promoting rooming-in, etc. as the patient desires.
Assessment provides information about knowledge and skills. The patient may benefit from current research findings. Interventions promote infant’s interest in nursing and allow frequent stimulation of the breasts.
Goal Met: Assessment of the patient’s previous experience, knowledge and skill with breastfeeding illustrates sufficient understanding with ample time for questions or concerns provided by discharge. Goal Met: Samples of formula upon discharge not offered, encouragement of rooming-in, and breastfeeding on demand allowed the mother and infant facilitation of continued effective breast-feeding until discharge, without problem upon reevaluation. Goal Met: Provided patient and infant praise for effective breastfeeding activity with evident increase in maternal confidence during praise, with continued growth of breast-feeding assurance upon discharge. Goal Met: Support person, husband to TH and father to infant and patient’s other two children, assessed with importance given to alleviation of misconceptions and social embarrassment associated with breastfeeding to given father
Praise patient and infant for effective breast-feeding activity.
Praise reinforces effective breastfeeding. Maternal confidence is an important factor in the continuation of breastfeeding,.
Assess support person network.
Social support is an important factor in the choice of breastfeeding and its success. The more affirmation a mother receives from members of her social network the better she copes with
breastfeeding. Provide patient with written and verbal information about daily nutrient and caloric needs during lactation: PNV, 4 servings protein, 5 servings dairy (1 quart milk), 2-3 servings fruit (2 vitamin C-rich), 2-3 servings vegetables (1+ green leafy), 2-3 quarts fluids. Teach the patient the importance of maternal nutrition. Written instruction allows patient to review material once she is discharged, and individual instruction promotes compliance.
encouragement for support by discharge. Goal Met: Patient provided with simple written but individualized verbal information about daily nutrient and caloric needs during lactation, with suggestions regarding continued compliance in relation to increased newborn wellbeing by discharge. Goal Met: The importance of maternal nutrition during 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. Goal Met: Frequency of feeding guidelines reviewed with patient, with importance of frequent and regular breastfeeding to promote the establishment of an adequate supply of milk, with patient demonstrating and voicing understanding prior to discharge.
Dieting during lactation can have a negative impact on milk production.
Review guidelines for frequency of feedings (Q 2 – 3 hours, or at least 8 feedings per 24 hours).
In the first few days, frequent and regular stimulation of the breasts is important to establish an adequate milk supply.
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