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    29 views14 pages

    Postpartum Assessment

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    api-402019114

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    © All Rights Reserved
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    MIs - Mectusky N3731 Course Packet 35 Student’s Name: Tori MCCormick Date of Care:1015 [17 r oo YOUNGSTOWN STATE UNIVERSITY 1N3731: Childbearing Family and Women’s Health Nursing POSTPARTUM HEALTH ASSESSMENT Client's Initials (VIM Age_@§ — LMP.Q}-05 EDD Jjia {17 Marital Status ¢) C4 ie Grvida_3 TJ pO ad obj Delivery Date: {015 {(._ Time: B:amPostpartum Day: __@ Blood Type/Rh:_Q _/_+ __ RhoGAM: YES If applicable, describe how labor was augmented or induced: Dactor scheduled cesarean section petart diy aad. dut to nigh Lisk tran first pregnancy Leese blog ‘Type of Delivery: Spontaneous Vaginal / Forceps / Vacuum Assist (Circle) Episiotomy: Type __ N/A Lacerations NIA Cc Length of: Stage 1_NIA 2_NIp 3_NIa A plannid Cesarean, section) Boy /Gint) Birth Weight: G__tbs__|3 oz. Length:_ APGAR: _9_, | lio Was pregnancy: @fanngd / Unplanned? Was birth control used? Yes &» ‘Type or mod of bith conto, fused: Ao mntth cartuol pang Used Prenatal Care: €ESV NO Number of Prenatal Visits: 80 (high vist) Bottle Feeding (Circle) Significant antepartal, intrapartal, or postpartum history: 2 with fist Pleqnanicy duu tO blood pressure spile pahent atso Lost baby in stcand pregnancy Significant maternal medical history: eve Current Health Status: adthy wit no furry Complications Did she attend childbirth education classes? YES / (0) N3731 Course Packet 36 PYSICAL ASSESSMENT. VITAL SIGNS Temp 46.1 Pulse 2Q__Resp_|&) _ BP !20/a0 OBSTETRICAL Breasts | (| mp Fundus Fy Lochia Scam Gmount, ru bra Perineum NO episiotomy 9 Paitin peyinsum SKIN / FLUIDS Skin: 6) Cool / Clammy / Diaphoretic Color: Consistent with genetic backgroumy Pale / Flushed / Cyanotic / Jaundiced Turgor{ Goody Fair/Poor Diaphoresis: YES PERIPHERAL — NEUROLOGICAL LocfAtes) Lethargic / Disoriented Upper Extremities: Movement @qUQ) DUGKEVOl upper extremines Strength et ee mes Sensation pqual in bath upper extremiftes Lower an nn Movement EQUAL botfi lower extremes Strength 1 ge pai ocean Sensation gues in both Lawley exiremhes siqniricart 5 Voss gale to Spinad recice iG NURSING DIANOSES (PRIORITIZE) O Risk for Fluid volume cit reladea tours atony | hamorrhaye Expected outcome f FUNQUIE IS Firm , OCHS Mowrak and thureis W10 evince oF humors mags page “By D inetrenve hss ve pertesia relatta to Mypovolemiq Ex pickel outcomes / hie man mill have Staple SIGNS , Oxy! pe arena A ee 5 4 hig va fe fy na ot jag tabi! ®@eise for peed patterng oF UL iN eiminagion re alka oY TO. UI pnd eere cares OF OfUStHUSG 1N3731 Course Packet 37 CARDIOVASCULAR Apical. Geaily / Irregular Rate 9 BPM Pulses: Radial: R +9 L +2 Pedal:R FO LTO Edema: Location / degree NO ¢Oemia_ present ciently Varicosities: NOMI Preune Capillary Refill: £3 Sends RESPIRATORY / OXYGENATION History of shortness of breath, smoking, allergies fo _Nistory oF siaortilss of breath. fadking o Respirations ES) / Labored "gies Dyspnea: With activity / At rest NO dyspla Cough: Non-productive / Productive No CQUQN present Breath Sounds: Cleat)/ Diminished: R / L Harsh: R/L_— Rales:R/L_—Rhonchi: R/L Wheeze: R/L Inspiration / Expiration 3 NIA GASTROINTESTINAL / NUTRITION Height: _5'3, Weight:_ 130 ibs Pregnancy weight gain: 30 \DS Usual nutritional intake from Basic Food Groups: (give Me 1, tabs , caffeine, street di NU NOT Iae toba ces or Shree t dregs, Inowever CoPFient In tar au piegaacay ‘Adequate nutritional intake for breast feéding, fissue repair: N t it Oe Feeding and tse repair NURSING DIANOSES, (PRIORITIZE) @ anwery related to Sudden change In neal Sodus (5) sleep pattern icrur eee re\ased to excirervenl* discomfort an erviornuntal interruptions N3731 Course Packet 38 Abdome SS) Firm / Distended / Tender | Bowel Sound Normoactiv9Y Hypo / Hyper / Nausea / Vomiting Bowel Movement since Delivery: bai No.Stool Only. gas mg GENITOURINARY Urine output: 100 ml piv CaftuAr Difficulty voiding since delivery QAAIUHCK Pla SLEEP / COMFORT a pattern: pe Teer eet Fes SO OH Usual methods of copisg WR pain/discomfort padient Uned ne pain nudicadians , Mes £0.16 St ‘wiih possible in ping TE DUSY PSYCHOSOCIAL HEALTH ASSESSMENT Social Interactions: Maternal-newbor attachment: tr it lattauud_and excitd For WN baby; +nis 5 atom second girl Relationship/interaction with her other children: Motu intirocts well with other chtd (mac) Mac (s very eXUHA fo Ploy with naw Ltile Sister Relationship/interaction with father of newborn: very S| QW DOr, ning o tl Su rau Bret CA SORRBT ADE toate a home/work environment in the past year? a " iMG Hu RTL,, affected her? (Vidtyyy Su (Sed Curing Tide point OF trie pranancy NURSING DIANOSES (PRIORITIZE) N3731 Course Packet 39 NURSING DIANOSES Interests/hobbies: )\q yiNg_WiHY r (PRIORITIZE) and Nonging out with fomuy ond Ervends Spirituality: Member of an organized religion? Not O numer OF an How important is her religion/spirituaity t6 he? id nk Gls nok rach ny cp wituality or weligion beret RIN FHEEE ISG Sense of Self: Ethnic and cultural background:Cerman |slovavian How does her ethnic/cultural background influence health | behaviors? of Five 1 back - Occupation or previous employment history: patient 1¢ Currenly On LON od Beret! — If employed, does she plan on returning to work? Yet When? Plot to return to lark in Decemnizer 30-7 DEVELOPMENTAL HEALTH ASSESMENT (Refer to article by Ramona Mercer) What is this mother’s stage of growth and development which you identified from your assessment data? (include data to support your conclusions): Personal Stages: this is mams baby #2 andSonud very configure WoturmMomrole Identify and define her expected stage of growth and development? Shy expuced hurseiF to pe a+ +MUS Stage bung thok it wos tur cecond @oud 3731 Course Packet 40 Has this mother successfully accomplished the developmental tasks of pregnaney (include assessment data)?es moter Nas Grawn proptrhy — nd tha baby dawbpid Correct What does this mother think about her present situation/eircumstance? Yery nappy with fuss) How does this mother anticipate changes r/t herself Stu fpntipaies gutting note Chua ta norms Wty weighs or 1g tbs Changes R/T family dynamics: (YMC (tne older CowghterLiuil nud to. get Ustd to Har nuda) little one What questions does this mother have at this time? | mo: lol ws ner second 40 Ground Si ‘What could you do to facilitate her growth and development? Taly to uy Qnout nur autt and ans +2 rend Btu welgne ‘What are the educational needs for this mother to care for herself, her newborn, and family? Thy Ir in bir (a1 planiud)-an\y-teaching- point WObld tt ae back on birth control an HOW Ud) WIN YN Qb oUt that Social Support Services (if applicable) (one aut opplicabee j family bas Support NURSING DIANOSES (PRIORITIZE) r N3731 Course Packet 41 DIAGNOSTIC TESTS: Describe diagnostic tests performed during pregnancy, labor & delivery, and postpartum (i.e, x-rays, sonograms, lab, fetal monitoring, EKG, etc) Test ee Test Result Probable Cause _ | Nursing Action aur pre dares for first} Soni Sonafienlt "lmimuckeneuhe keveadig mane lprenadatscha | | Mey Sad gener lovagnat yn ut was a girl with pa eee, Ne a hm ies Norma growth honth hy chu ong ae ic paren pS wit inane risk doctor ung mq ~ hans Wereiaun [no abnormal aseNt consicit py yachon ] fo ruarsing achon lab afaws’ — jonczamontn eye Su pater Freahoney required Shanta ‘stance IF She erg Fe ragiobin recieve Dio! eater Wy tumogtobin 4 actor Stata "nyo wewhn Use Wadcn ard = Imonttor closely FeCl Montorng | fal mnong vapy 18 within | pamentis @ nian jiwatcn hart raze si con dir st cenaecy age pe? Sas mn Feta aistress meee within Part uumits; Mr cenaney Frequent porens He Be Bin nor ete Eko dome — [Baby Henan Past | nist sue] MONIT | na levenymonth [Norma tim i tol00d pre aul! ining pregnoncy om Y vor, with pregnancy Jauaring Pregnancy ibostpai kano Within normal a Wits N3731 Course Packet 42 MEDICATIONS: Include all Routine and PRN medications used during Labor, Delivery and Postpartum. Describe type, amount, pharmacological actions, times of administration, reason for administering the drug, and nursing actions. List here and attach Medication Sheets for each med. Lovenox Yoma subg injechon ketorolac 'Smq W push @iuoo @ aco Morphine 3mgimi @1000 PRN) 'duprofen €00ma ag Z0Fran mg \¥push Qo EVALUATION AND INDICATION OF STUDENT'S PROFESSIONAL GROWTH: The following narrative should include but is not limited to: (1) Summary and evaluation of total care implemented for mother and newborn (2) What you would do differently GB) What you would do for this expanding family if you were the primary nurse form admission to discharge (4) Discharge planning (5) What you leamed from this family and from this clinical experience ‘Type the above Evaluation on a separate sheet and attach. REFERENCES (APA) FORMAT ONLY (Must include OB text, do not use care plan books!) Tori McCormick Maternal Database October 5, 2017 My patient was a twenty five year old woman with one living child. This was her third time being pregnant however she did miscarry during one pregnancy. She delivered a baby girl via cesarean section today at 8:03 am. | first introduced myself before we took her back to the delivery room, both her and her boyfriend seemed very excited for the new baby. After the section we took baby back to room with dad and allowed mom to rest. After allowing adequate time for mom to get acquainted I preformed an assessment and vital signs, finding no abnormalities after birth. think what I would have done differently, would be to spend more time with the baby as well as the mother. They had a lot of family in their room after the delivery however it should not have taken away from my time with mom or baby. | seem to be forgetting that the baby is also my patient as well so although the families were eager to get the baby back after | did my assessment and completed the first bath I shouldn't have rushed with it. I need to manage my time better to adjust to caring for both mom and baby. If| were this patient's primary nurse I would focus on encouraging bonding between the mother, father and their newborn. The mom's family and dad’s family both were either in the waiting room or patients room. It was really heart warming S Uindapul 1 0 dush a dupparbic fut, to see all of them come out to support these guys but the mom baby bonding is of the upmost importance these first few hours after pregnancy. | would have been a little more adamant about making sure the mom had privacy to try and breast feed even if it meant asking the families to step out. I would have also asked specific questions if the mother had what she needed to help care for the newborn such as a breast pump, prenatal care, best sleeping positions, and car seat safety. The discharge planning would include all of what I had mentioned and more information on support groups, education,and common complications that happens after the hospital stay. Today I got to see a mother’s love and instant connection towards a newborn who eager to learn new things and how to provide the best care for the baby. | also saw the bonding and the attachment process happening. | felt that educating my patient of proper perineal and breast care was easier for me to do, meaning I felt more confident with my education than I have in the past. Th who uel sos e a e A page Ge, 'N3731 Course Packet Student; TOU! MCCOrMICe Date of Caren) dobauas | Youngstown State University | i ing Program N3731: Childbearing & Women’s Health Nursing Nursing Care Plan Show No Signs Gt Fluid Volpe Cit OU) Wt, FE FUOdAS WII BE Erm, (oChia. CIO GrigtHure eG VIGIL OF Ort AQ Behavioral Objectives, Rape real Qmoun- k r FLUId voluwul FUNGUS 15 Free oc, Uticit related to [iS n aduigic, ama oe 5 te lhe aa gid itor VIFOIS (4 pulse, To aetect signs oF Rien "renr prakenge and |iemorrnage ishoce (Monitor postpartum IMaiology studies. Wen. NO Gbuormastte ity vital Ciga s (5) All (QD Valuso indus uteri tore (do nor Jk Withit) rarge ane ne abe Pueisneizak pie dung |Fun ae is nor sss tone reponse fea eed! Fenaat "PPO Wexpress Wicrine wots Oy ron phe user (No clots found Béxpiain 0 woman erurm Pah ent sua sctuil braces Ok invoiution gnd FP Te Involve har | (7) i casceu RRR Orrin rd Ra ait cok a clan ape fay 10 e @ @ , pags B10 N3731 Course Packet Student;TOr TiCCorauce Date of Care: WGHrnas Database ‘Youngstown State University Department of Nursing Bachelor of Science in Nursing Program N3731: Childbearing & Women’s Health Nursing Nursing Care Plan Goal: Parent will Nat Nave signitiCant biggd /0SS QUUNING CESaItan stcfICti /¢aC) oo Frid tore Wilk nace stab Veal ORE, ory gely usr ed code 14 fo kines lage jobin mumadecn yun | i Evaluation, rntons ry, Raa OF Fats nec fmani ser vital sians,oxyge(S) To assess for hypo vowm No anormal ines Slue ard QUCHOUG HSSve rusian Nursii lursing Interventions Documented DPrepare for suraicat Diagno: havioral Objectives merrective tissue i PertUSiOn relued to Signs Ox ‘ary Dypovoteme Marcia! blob gases . 0d adsvase tuntadacrit Ind tUmagiobin LIVE Suppemeniary orygen{9 to Provids Odditonas ora Oryqenahon to Hss eS Suction as needed, arc) I) To maintani Cor Instr ora Qurwiay, QIN GirWay 41 Onyqemata Occontar idad aoe Dro provics infor maven) pevracdosis or hypoyia Di evererutavalic clots ibe aah ig suction 6 Nt a 00d qoasee etd ied (3) fo gain A vii Course Packet Student: You MCCprnicy pag. 4eu Date of Cares ievna) OKTOIZOA ‘Youngstown State University Department of Nursing Bachelor of Science in Nursing Program N3731: Childbearing & Women’s Health Nursing Nursing Care Plan Goat: Pachgrt Will Nave 110 Girly vowing mi¢nin 3-4 Nour biadaty ile vemguniin fs i i Nursing Interventions, Documented Rationales (cite) Assess position ang To asurtain ifany Character oF UTI, Fundigturttuy inervenitions Ore Rist tor adteed — |iotvanwiht void within [and bioader TY ndiagted becouse oF Chuminahan relaed ofara en pry piadde MUU iniat and Otriyal trauma dnd Compiettly aoe 70 ASSESS Ong uacy oe eigen araora tp Or dierua biaday Md BY tv nse GF userine Qfony {9 bar (B70 encourage voiding Potent vorded gS wimin Sheet Dencovrage oras Hud intae (SD) Carntterize as Wecussary with indwelling br straight wutnad 1D To repiad any Fives lost uit owt and Dtewent Gihyarasnon Ove ensure blader Hiden Utrine O4Ony LY Fluids encoungd luater given and ip. vines eS ps 110g SI @catunr Wasnt uusary ol ep wh yt eager yyy yale ho ‘WWLOL ouatiodxa yeoruyo woyy pours] sem yey papnjouy (q ‘reo Butsinu Jo stsKfeue pue Areuruns papnyouy (e (6601) :ymoa-y[9s yeuoyssayord Jo woreWuoMMIOCT “7 “saatjoalqo,sjeo8 Jo ywuourmene 103 Azessooou suoneoytpow payyioodg (9 soataa{go Jo juatuurEHE premoy ssaxBord oddns 0} wep paptaoze (4 ‘ayoafgo,qvod Yous Fuysaut premoy ssarsoxd paunseayy (e (%s) geo Businu jo uonenpeAag “| uopeneag JeULOJ Ya 03 Strpsos0e paouasayas pu pay!9 kpoarioy (9 ‘ayajduoo puv “yBnosomp ‘aqemooy (q saanoalgo puv ‘suoyoe aansisse Susinu ‘sasouserp Suisanu 0} yueAdjoy (& (07) ‘229M saqeuoHes poywouundocy °Z stoyoe Susinu yuapuodapu papnjouy (p siopu0 [eotpawe 0} yudUIpIod suoNoe annesOqu{[OD papnjoul (9 ang00 0} a1om suonoe BuIsINU Hoyo MOYAIYA Papnjouty (q sasouseip Susinu aup 40j ayeudorddy army (e 9402) :suonoe Butsiny “1 ope yuaurayduy wogaau Jo 129 40} spaau jeuonvonpy (P spaau tnjeay yentawudojanaq, (9 spaau tppeay peroosoypcsg (q, spoau ypqeoy eorskyd (e (9s) :jenuatod 10 yentoe 40 sasouseep Suisane paynuapy “¢ poznuiond pur ‘uontiayponetuios

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