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Post Partum Charting

This document summarizes the postpartum assessment of a woman and her newborn female infant. It notes that the woman had a normal spontaneous delivery at home and details her vital signs, breast examination, lochia flow, and emotional state. The newborn's vital signs and reflexes were also assessed. The woman was educated on perineal care, nutrition, breastfeeding, and immunizations. Both the woman and newborn were found to be stable with some risk of infection, so hygiene and temperature regulation were emphasized.

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Maria Deanna Seguerra Cantos
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23K views3 pages

Post Partum Charting

This document summarizes the postpartum assessment of a woman and her newborn female infant. It notes that the woman had a normal spontaneous delivery at home and details her vital signs, breast examination, lochia flow, and emotional state. The newborn's vital signs and reflexes were also assessed. The woman was educated on perineal care, nutrition, breastfeeding, and immunizations. Both the woman and newborn were found to be stable with some risk of infection, so hygiene and temperature regulation were emphasized.

Uploaded by

Maria Deanna Seguerra Cantos
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

POST PARTUM Maiden Name: Age: Husband: Place of Delivery: Home Time and Date of Delivery: August 17,

2011 Midwife: Type of Delivery: NSD Gender of the Baby: Female

Post natal Assessment Vital Signs: BP: 110/70 mmhg RR:22bpm PR: 78 bpm Temp: 36.4 C Breast: engorged and facilitates breastfeeding Uterus: firm and contracted Bladder: voids freely to a yellowish colored urine moderate in amount Bowel: positive bowel movement Lochia: with whitish vaginal discharge, scanty in amount Episiotomy: none Homans sign: no pain felt upon dorsiflexion Emotional Status: with stable emotional status Bonding with infant: seen cuddling and breast feeding her baby

Health Teachings: -proper care of perineum, washing from front to back to avoid infection -Instructed to eat Iron rich foods such as green leafy vegetables and Vit. C rich foods such as dalandan -Importance of breastfeeding -Proper way of breastfeeding -Proper breast care -Importance of complete immunization of the child -Instructed to visit the health center for check-up after six weeks

Focus -Risk for Infection

Data -with traumatized tissue -with slightly pale conjunctiva -with slightly pale ,lips with pale nail beds ;

Action - Evaluated clients hygiene. Stressed need for hand washing before and after perineal pad changes and before

Response -Verbalized proper care of perineum -Verbalized the importance of diet rich in protein, carbohydrates, iron zinc and Vit. A , B-complex and C

capillary refill time of 1- handling breast infant. 2 seconds -Noted the amount and color of lochia flow -Assessed nipple for cracks and fissures. Provide or reinforced information regarding breast and nipple care -Discussed dietary practices. Stressed need for increased amount of food rich in protein, carbohydrates, iron zinc and Vit. A , B-complex and C

Infant Assessment

Vital Signs: T: 35.6 C CR: 122 bpmRR: 29 bpm

Head Circumference: Chest Circumference: WT.: -with good sucking reflex - with positive rooting, babinski, Moro and hand grasping reflex -Vitamin K given

Focus -Risk for altered body temperature r/t immaturity of hypothalamus .

Data -Body temp=35.6 C

Action -Assessed newborns temperature. -Assisted parents in recognizing importance of heat regulation ; helps protects newborn from harm by temperature extremes -Assessed environmental temperature and neonates dress and coverings in relation parental attire -Suggested of using appropriate hat in all temperature.

Response -Temp=36C -Mothers verbalized the importance of maintaining the temperature of the baby -Seen wearing hat

MARIA DEANNA S. CANTOS BSN IV/ GROUP 5/SLSU

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