Age: 32 yrs. old Ward/ Bed Number: OB PHIC, Bed Number 4 Impression/ Diagnosis: G3P3 (2103) Pregnancy Uterine Full Term, Large for Gestational Age, Baby Boy, Delivered in Cephalic Presentation via Spontaneous Vaginal Delivery Date and time of interview: December 8, 2020; 8:00 AM
DATE/ TIME FOCUS DATA ACTION RESPONSE
December 8, Risk for deficient 24 hours MIO is 1L Health teaching on 10:30 am. Verbalized 2020; fluid volume intake vs (include importance of understanding of 8:00 am output of mother). adequate fluid intake importance and risks of (Monitoring Intake and (2-3L). and normal adequate fluid intake. Output that helps amount that must be 11:30 am. Client caregiver ensure that ingested. Highlight became more patient has proper case where huge water cooperative and ingested intake of fluid and other outputs are present for 300 cc of fluid. an hour nutrients) showed that postpartum mother after intervention. patient only consumed through diaphoresis a total of 1000 mL and diuresis. water in past 3 shifts. Explain effects of Verbalized that even diminished fluid volume with humid or dehydration such as environment, she barely dizziness, fatigue and consumes 500 mL of connection of lesser bottled water for 8 breastmilk production hours. - “sa sulod sang to dehydration. 8 ka oras, wala ko gane If not comfortable with natunga ang isa ka litro this intervention, na tubigan na dala gradual increase of sakon sang akon fluid intake can be asawa.” performed instead. Verbalized not wanting K.C. to drink water and only consume 1-1.5 liters of water a day. K.C. Disturbed sleep Unkept. Nurse notes Teach the importance 10:30 am. Mother pattern related to tired look as evidenced of rest in well-being of verbalizes importance of exhaustion, by ragged appearance both mother and child. rest for both her and her excitement of of the mother. For instance, extreme child. childbirth and Client verbalized sleep fatigue promotes 1:00 pm. Utilizes environment disruption. - “natuyo pa development of breathing techniques unconducive to rest ako ma’am kay tatlo gid postpartal depression. and other methods to bala ka adlaw na sunod Explain that ‘humid induce sleeping. sunod gakadistorbo ang environment’ Mother wears clean tulog ko kay ang ward experienced is normal and dry clothes while du ka busy, gahod kag due to body induced sleeping. sobra gid kainit.” diaphoresis but Significant other “Ang bata ko pa abi environment must be takes care of baby ma’am naga hibi pa maintained to keep the while mother is kada gab e kag child warm. resting. napadede ko pa.” Kept clean and dry. 3:00 pm. Asleep. K.C. Provide comfortable K.C. and airy hospital gown. Promote ventilation. Assure mother that noisy feedback will be evaluated by the authorities. Teach breathing techniques, meditation and relaxation methods to induce sleeping. Encourage cooperation of significant other in taking care of the baby. K.C.