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(specify) or maternal anxiety, stressor pain
SHORT TERM GOALS Infant will latch-on with nutritive suck and audible swallowing as evidenced by appropriate # of stools and voids for age with no supplements Mom free of moderate to severe nipple pain and engorgement and issatisfied with breastfeeding Fundus will remain firm & midline at appropriate fundal height with smallmoderate rubra lochia
LONG TERM GOALS Same
NURSING INTERVENTIONS 1. Assess mother’s breasts, nipples, pain level when breastfeeding, and satisfaction q 4-8 hrs 2. Assess breastfeeding dyad for proper positioning and latch-on each shift or prn 3.. Monitor infant’s stools and voids 4. Teach frequency, duration, assessing milk supply, wake-up techniques, etc (all topics) and reinforce as needed 5. Assist with feedings as needed or requested to help with positioning and latch-on 1.Monitor fundus, lochia, VS, color, and cap refill q __ hrs 2.Monitor urinary output and for bladder distention 3. Teach patient to massage her fundus frequently 4. Administer fluids and pitocin as ordered 5. Monitor labwork 1. Assess for bowel sounds if C/S 2. Provide diet as ordered 3. Monitor for n, v, d 4. Progress diet as tolerated and record percentages 5. Teach about dietary needs 6. Provide patient selection of meals if available
Risk for ineffective tissue perfusion r/t blood loss secondary to childbirth
Color acyanotic, cap refill< 3 seconds,; vital signs within range of admitting vital signs; Hgb ≥ 10
Altered Nutrition, imbalance: less than body requirements r/t decreased intake, decreased peristalsis secondary to surgery (C/S) and increased metabolic needs and lack of choices (BOTH)
Will consume 50-75% of prescribed diet without n, v, d
Will consume ≥ 75% of regular or prescribed diet without n. v. or d
Risk for constipation R/T
Will have active bowel
Will have at least one soft
1. Assess for bowel sounds and passing flatus
pain. Teach to look at color of urine 1. Instruct to drink to thirst and monitor color of urine 4. f q 4-8 hrs 2. edema. Monitor I & O 3. p. fiber. light yellow urine 1. Administer xylocaine spray or pain meds as needed 5. & limited intake Altered family processes R/T to need to integrate newborn into the family Will void 200-250 cc X 3 within next 6-8 hours for 1st void After the first 3-4 voids the STG and LTG are the same Will void q 2-4 hours clear yellow urine with burning. Encourage to void q 2-4 hrs while awake 3. or frequency Will maintain balanced I &O Will have moist mucus membranes. limited intake and decreased mobility secondary to Cesarean delivery Risk for constipation r/t inflammation. and walking to keep stools loose and reassure these will help with skin integrity 4. good skin turgor. Assess family’s learning needs. Identify barriers to learning Parents verbalize 50% of instructions without assistant and participate Parents verbalize understanding or demonstrate care without . Assess for previous pattern and problems 2. preferences and for attachment and claiming behaviors 2. Progress diet as ordered and monitor for tolerance 3. then modified I & O 5. Strict I & O until voids > 200 cc X 3. diaphoresis. Administer medication (suppository?) as ordered 1. 2. fear of tearing stitches or pain secondary to vaginal delivery sounds in all 4 quadrants or pass gas through rectum semi-formed bowel movement by discharge 2. Assess skin turgor. Assess for bladder distention and b. chills. Administer diet as ordered 3.decreased peristalsis. dehydration and edema and inflammation of urinary meatus Caesarean delivery) secondary to removal of foley and decreased muscle tone secondary to anesthesia Vaginal delivery secondary to vaginal birth Risk for fluid volume deficit r/t diuresis. Use “tricks” if necessary 7. Administer stool softeners or other aids as ordered 1. Encourage to drink to thirst 4. Cath prn Will have soft bowel movement before discharge with use of stool softeners Will return to pre-delivery bowel pattern within 1-2 weeks of delivery without softeners Altered or Impaired urinary elimination r/t dieresis. Encourage fluids and walking or rocking 4. mucus membranes. Assist to BR as needed 6. decreased mobility. Teach importance of fluids.
Assess skin q 4-8 hrs 2Apply ice after a vaginal delivery for 12 hours according to protocol 3a. tear. how and when to change peri-pads and when to call HCP 1. respiratory rate ≥ 16. Instruct patient and family to assess incision daily 4. f. color acyanotic Will not fall during hospitalization 1. Assess pain level q 2hrs 2. color acyanotic Will have complete return of sensation to lower extremities within 1-4 hours Afebrile and skin will clean. Risk for infection r/t interrupted skin barrier and/or multiple ports of entry and/or urinary stasis Risk for impaired gas exchange r/t medication side effects of Duramorph (respiratory depression) C/S DELIVERY Risk for injury r/t decreased mobility secondary to epidural anesthesia VAG DELIVERY Risk for impaired skin integrity R/T disruption in skin barrier secondary laceration. or episiotomy or Cesarean incision Altered nutrition R/T in daily care Pain will be 3 or less on scale of 1-10 with the use of narcotic medications assistance and verbalize a plan of care for home Pain will be 3 or less on scale of 1-10 with the use of OTC medications and some narcotic medications 3. inflammation and/or severed nerve endings • Perineal or incisional • Afterbirth pain • Hemorrhoids • Lactation suppression • Sore nipples • Engorgement. etc. Instruct patient in sitz baths. Have Narcan available 1.) 4. 3b. dry & intact Breath sounds clear & equal. Instruct patient in peri-care. breath sounds clear & equal. Monitor blood sugar as ordered (ac & hs?) Afebrile and skin without redness. Utilize non-pharmacological methods (See slides for specific interventions) 3. Monitor VS and lab work q 4-8 hrs 2. etc. Instruct about pain management (when to ask. voiding without b. Assist to restroom first few time 3. Monitor for return of feeling and motion 2.4. Administer medications as ordered Temperature will remain < 100. p. drugs available. Aseptic technique and good hand washing Teach patient about postpartum hygiene 1. respiratory rate ≥ 16. Monitor for orthostatic hypotension 1. and intact Temperature < 100. Teach and reinforce as needed 1. edema.and adapt to parent hood Acute pain _________r/t edema. Encourage rooming-in and baby care 4.4. and incision / perineum clean. Monitor RR q 1 hour X 24 hrs 2. Teach pt and family side effects and plan of care 4. dry. ecchymosis. Pulse ox for 24 hrs 3. Assess incision or perineum q 2-4 hrs 3. or discharge with edges intact Blood glucose will remain Blood glucose will remain . Assess breath sounds and urinary staus q 4-8 hrs (noscomial infection?) 4. incision clean dry & intact (because most common noscomial infections) Breath sounds clear & equal. methods to use.
imbalance of glucose and insulin utilization (GESTATIONAL DIABETES) 70-110 mg/dl with the use 70-110 without the use of of sliding scale insulin insulin 2. etc Parents will verbalize potential coping strategies or support systems and will verbalize a plan for adjustment to parenthood and newborn after discharge Altered sleep patterns R/T hormonal changes. stillbirth. discomfort or pain. Refer to social services or psychological counseling Recognize period of euphoria is normal # 1 Assess prior needs for sleep and rest #2 Organize nursing care and other hospital personnel interruptions #3 Limit or schedule visitors #4 Teach to nap when baby naps. blood loss. congenital anomalies. fluids. postpartum. to gradually increase activity. baby care. diuresis. newborn in NICU. Provide diet as prescribed 3. or newborn This only applies if it is problems and past coping a true crisis some strategies examples are emergency delivery. Reduce unnecessary stimuli and stress 6. Encourage parents to verbalize including her story and spend time with parents 2. Assess for previous coping strategies and social support 3. Encourage rooming in and parents to participate in care or to visit NICU and bring toys or pictures 4. Reinforce diabetic teaching related to diet and exercise 4. Assist in identifying new coping strategies and possible support services 5. and frequent interruptions from hospital personnel and visitors STG: Patient will take at least a 1-2 hour nap during day LTG: Patient will verbalize a plan to ensure adequate rest after discharge . other physical changes. and vitamins #5 Medications as last resort Risk for ineffective coping Parents will verbalize R/T situational crisis feelings about birth. Instruct in importance of follow up and risks for future development of diabetes Recognize importance of Rubin’s Role Transition 1. and importance of diet. neonatal death.
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