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THE CLIENT AT 1 WEEK FOLLOWING DISCHARGE

CLIENT ASSESSMENT DATA BASE
Circulation
Vital signs within normal limits

Ego Integrity
Emotional tone and responses may vary from one of delight to a sense of overwhelming disorganization or anxiety,
especially in first-time mother. Irritability, crying, “postpartum blues.”

Elimination
May report voiding difficulty or stress incontinence
May report difficulty with bowel evacuation, with decreased frequency, hard-formed stool

Pain/Discomfort
May report continued discomfort associated with afterpains.
Engorgement may be present in lactating client.

Safety
Episiotomy or cesarean incision free of edema, indurated areas, redness, and exudate; tissue edges approximated

Sexuality
Uterus nontender, palpable at symphysis pubis.
Lochial flow scant and pinkish-brown in color (serosa) and of 4–10 days’ duration.
Breasts in lactating client increased in size with increased milk supply.
Nipples free of redness, cracks, and fissures.
Engorgement may be present in lactating client, subsiding in nonlactating client.

DIAGNOSTIC STUDIES
Urine: Negative for albumin/glucose.
Additional testing as indicated; e.g., UA, culture and sensitivity, Hb/Hct or CBC to include WBC count.

NURSING PRIORITIES
1. Promote maternal/infant well-being.
2. Foster optimal adaptation to physical emotional changes.
3. Provide anticipatory guidance for optimal integration of new family member and adaptation to role changes.

NURSING DIAGNOSIS: FATIGUE, risk for
Risk Factors May Include: Physical and emotional demands of infant and other family members,
psychological stressors, continued discomfort
Possibly Evidenced By: [Not applicable; presence of signs/symptoms establishes an actual
diagnosis]
DESIRED OUTCOMES/EVALUATION Identify basis of fatigue and individual areas of
CRITERIA—CLIENT WILL: control.
Report improved sense of energy.

. reading a book or having a glass of warm milk or wine). and overcomes nutritional deficiencies. Assess work capabilities and of labor reduces amount of responsibility that responsibilities of each member. Limit number of visitors. promotes healing. Note: Approximately daytime and recommend that mother naps when 5 wk are needed to regulate the infant’s cycle. statements suggesting extreme fatigue indicate inadequate sleep and rest. Determine infant’s sleep-wake cycles. promotes sleep. client assumes and allows client to conserve energy. excessive crying) . Encourage restriction or lessening of outside Helps prevent overexhaustion. deep circles under the eyes. relaxing Aids in relaxation.. Assists client in creative problem solving to identify times available for resting and napping throughout the day. infant does. Cumulative sleep loss must be overcome as soon as possible to facilitate psychological and physiological recuperation. Assess availability/use of support systems Identifies needs and means of physical and (including doulas. misinterpretation. emotional assistance. inappropriate behaviors (e. activities. NURSING DIAGNOSIS: KNOWLEDGE deficit [LEARNING NEED]. hesitancy in or inadequate performance of activities. as appropriate).ACTIONS/INTERVENTIONS RATIONALE Independent Discuss signs of excess physical and Lack of energy. Suggest Helps infant to maintain progressively longer ongoing efforts to modify the infant’s behaviors wakeful periods during the day and to sleep to promote more wakeful periods during the longer stretches at night. and emotional fatigue. Encourage client to establish a quiet. unfamiliarity with resources Possibly Evidenced By: Verbalization of concerns/misconceptions. Provide information about daily iron and vitamin Helps restore Hb levels needed for oxygen intake and the need for a balanced diet. regarding self care and infant care May Be Related To: Lack of exposure/recall. Self-monitoring and awareness of developing problem allow for timely intervention.g. transport.g. Determine family structure and number of Household tasks should be shared so that division members. Review family’s daily routine. routine prior to retiring (e. Review intrapartal and early postpartal events. which may contribute to feelings of excess fatigue and inadequate energy levels.

50% do not ovulate during the first menstrual cycle. Provide information regarding resumption of Among nonlactating women. an emotional letdown in the early postpartal with insomnia. Among lactating women. individual and infant needs. Provide information as needed about signs and Identifies potential problems necessitating prompt symptoms associated with endometritis. poor concentration. period. Ascertain understanding of normal physical Identifies normal and abnormal physical findings. . independence. CRITERIA—CLIENT WILL: Perform necessary activities/procedures correctly and explain reasons for the actions. Couple can resume sexual activity when client is comfortable and lochial flow has ceased (usually 3–4 wk after vaginal delivery). Such feelings are intensified by fatigue and crying infant. and Most mothers. Verbalize understanding of physiological changes. incisional infection. when appropriate. of these. DESIRED OUTCOMES/EVALUATION Identify individual learning needs. Provide and encourages anticipatory planning. Client who underwent cesarean delivery should delay intercourse until 6 wk postpartum. enhancing information about appropriate measures to take.to 6-wk checkup. wk postpartum. and studies indicate increased risk of complications or untoward outcomes for pregnancies spaced close together. especially first-time mothers. changes at 1 wk following discharge. mastitis. solving. evaluation/intervention. 15% resume menstrual cycle by 6 wk postpartum. and the need to notify healthcare provider. Note reports verbalize a sense of disorganization and feeling of of depressed mood/tearfulness. postpartal or “baby” blues occur in 50%–80% of clients. Couple needs to select and use a temporary or permanent method of family planning that meets their individual needs. Conception could occur prior to the 4. emotional lability. Symptoms are usually transient. beginning about day 3 postpartum and often resolve without therapeutic intervention in 1–2 wk. Modify behaviors. and UTI. headaches. and 80% of the first menstrual cycles are anovulatory. Identify emotional concerns at this time. discuss normalcy of these feelings. Discuss plans for contraceptive usage. In addition. ACTIONS/INTERVENTIONS RATIONALE Independent Determine client’s perception of problems and Establishes individual needs and promotes problem needs. 40% menstruate by 2 menstrual cycle/ovulation and sexual intercourse. should a problem arise.

Continued low estrogen levels The Client at 4 to 6 Weeks Following Delivery. Helps strengthen and tone perineal urethral tightening exercises. and vitamin C. . Effectiveness Training (FET).g. tenderness. iron. unrealistic expectations for self/infant/partner. components and alterations in mobility increase redness. Family developmental needs of client/couple.) use of water-soluble jelly. excess fatigue. risk for altered Risk Factors May Include: Lack of support between/from significant others. dietary role. Reinforce information. less than body requirements. for lactating Facilitates positive adaptation to breast feeding client regarding physiology of lactation. or contraceptive creams or jellies for lubrication. include information on caloric recuperation.. NURSING DIAGNOSIS: PARENT/INFANT ATTACHMENT. financial. presence of stressors (e.) Emphasize need to prevent venous stasis. and vasoconstriction of labia minora and labia majora is delayed. Discuss/evaluate ongoing exercise program. and healing in postpartal needs. Exercise helps tone muscles and restore body Provide information about importance of adhering contours.. e. employment. PARENTING.Provide information about physiological changes Reduction in rapidity and intensity of sexual in sexual response postpartum. and related support groups. breastfeeding Helps meet continued educational and support groups. homeostasis has been re-established. restoration. housing. (Refer to ND: period.g. cocoa butter. videos. Instruct client in appropriate perineal muscle. and Changes in circulating volume or cellular review signs of phlebitis formation. Recommend books and other written materials. result in vaginal dryness. parenting classes. (Refer to CP: response is normal. measures to reduce discomfort of engorgement. and nipple/breast care. protein.g. Discuss parenting role realistically. Size of orgasmic platform and strength of orgasmic contraction are reduced. muscles to improve control of urine flow. multiple demands of home/family. Identify community resources. concerns. use of outside helper/extended family members) Possibly Evidenced By: [Not applicable. as appropriate. presence of signs/symptoms establishes an actual diagnosis] DESIRED OUTCOMES/EVALUATION Demonstrate appropriate bonding behaviors.g. Provide information for client with cesarean birth Lifting any object heavier than the baby for 2 wk regarding activity level and exercise and the need after delivery may contribute to stress on healing to avoid strenuous lifting/stretching. e. Review nutritional needs for lactating or Helps client meet nutritional needs necessary for nonlactating client. to prescribed program. possibly necessitating ND: Sexuality Patterns. risk of thrombophlebitis. Nutrition: altered. Kegel exercise. e.. altered. warmth. CRITERIA—CLIENT/COUPLE WILL: Identify concerns related to parenting. calf pain. tissues and result in wound dehiscence. Reinforce need for evaluation by healthcare Necessary to ensure that physiological/emotional provider at 4–6 weeks after delivery.

and comfort/skill in parenting. diapering/feeding) will need closer monitoring and more extensive support. In American culture. Develop plan for subsequent visits. helps client focus on possible problems.. preparation for parenting. . Determine client’s/couple’s perception of infant Client/couple with unrealistic perception of infant behaviors. and role modeling of parenting skills. highlighting Helps promote positive adaptation to new role. risk for Risk Factors May Include: Tissue edema/engorgement. mechanical trauma.g. calls the infant by name. talks in a high-pitched voice. areas of particular concern. and holds the baby close. CRITERIA—CLIENT WILL: Verbalize relief of pain/discomfort. or to community programs provide home visitation. Volunteer support Beginnings. First Visitor). Directly impacts on ability/desire to gain maturity level. NURSING DIAGNOSIS: PAIN/[DISCOMFORT]. behaviors or who voices displeasure with specific caretaking tasks (e. volunteer support program (e. home healthcare Provides support and reduces possible negative agency. excessive fatigue Possibly Evidenced By: [Not applicable. attachment is considered Document verbal and nonverbal responses and positive if the parent makes eye contact with the presence of positive or negative behaviors. uses an en face position. Bright outcomes for infant/family. ACTIONS/INTERVENTIONS RATIONALE Independent Assess client’s/couple’s interaction with infant. ongoing resource groups. Lack of culturally appropriate attachment behaviors places infant at risk for abuse. Note impact of culture on interaction.. infant. reaction to conception. presence of signs/symptoms establishes an actual diagnosis] DESIRED OUTCOMES/EVALUATION Use appropriate measures to promote comfort. Assess client’s/couple’s strengths and weaknesses. Identify available resources. follow-up as indicated.g. Different cultures have different values/beliefs about what constitutes positive attachment behaviors. Collaborative Refer family to social services.

because it makes the breast and nipple hard. discomforts associated with engorgement. creating one nipple is sore or cracked. Encourage use of creams. emptying during feeding. as well as impair coping and client’s response to pain. possibly causing further engorgement. Suggest continued sitz baths 3–4 times daily for Promotes vasodilation and increased tissue 20 min if site of episiotomy is uncomfortable. especially at the beginning of the feeding when the infant is most hungry and sucking is most intense. Increasing frequency of feedings during engorgement promotes comfort and helps to empty breasts to ensure an adequate milk supply. gradually increasing feedings by 2 min sucking for too long reduces milk supply and each day. note feelings of Fatigue can negatively affect lactation and increase excess fatigue. By 20 min after feedings. alleviating pain and tenderness caused by heavy. Helps determine severity of problem. tissue approximation indicates need for further evaluation by healthcare provider. . enhancing healing. Inspect site of episiotomy repair or cesarean Continued discomfort. Continued tenderness lochia. engorged breasts. Identifies individual needs. Baby suckles most nipple for several feedings in succession if only intensely in the first 5 min of the feeding. Limit feedings to 5 min on each breast when nipple Helps limit exposure to trauma. making it difficult for the infant to suckle. plastic liners promote bacterial Instruct client to change pads when wet or moist. growth and may cause skin breakdown. Note fundal height. environment. Review sleep/rest pattern. however. air drying of nipples for Helps toughen nipples and prevent cracking. tenderness. or oxygenation/nutrition. and allowing nipples to remain in a moist avoidance of plastic liners inside nursing pads. Note presence of foul-smelling wk following discharge. apply breast binder. Note frequency and length of feedings in Engorgement may interfere with breastfeeding. may signify infection. Advise client to avoid reduces milk production and engorgement. or loss of incision. Supports and uplifts. limiting is cracked. breast stimulation or milk expression. or redness. edema. Suggest warm compresses/shower before feedings Aids in let-down reflex to promote easier for lactating client. fissures. removal of too much milk increases the milk supply. Inspect nipples for any areas of indurated masses. Sore or cracked nipples can create intense cracks. Recommend application of ice or cool compresses Provides vasoconstriction of blood vessels. greater pressure on the initial breast.to fourth-degree lacerations were present at delivery. avoidance of soaps. however. for 20–30 min 3–4 times daily. from engorgement. Engorgement is usually more severe in primipara than in multipara. lactating client.ACTIONS/INTERVENTIONS RATIONALE Independent Determine location/nature of discomfort. if third. Instruct lactating client in removal of milk through Removal of milk from breast often provides relief manual expression or use of breast pump. assess for rigidity or guarding Uterine discomfort should have disappeared by 1 on examination. Prevents or client. Encourage use of supportive bra. for nonlactating promotes local anesthesia and comfort. Inspect breasts for degree of engorgement. discomfort during lactation. Initiate feeding on nontender/less tender promotes engorgement.

husband. can serve as a catalyst to growth and enhanced especially for first-time parents. concern for future assessments. Discuss client’s/couple’s perceptions of First-time parents have been known to experience adjustment to the infant and to parenting varying degrees of stress and crisis associated with roles and responsibilities. Provide information adjustment to their child and integration of this about normalcy of feelings of inadequacy.g. private facilitating postpartal adaptation. home care service). lactating client. relatives. Document areas of adaptive capacity. Encourage client to rest and to assume only the Allows client to focus energy on interaction responsibilities directly related to care of herself between infant and herself. especially 30–60 min before during feeding. facilitates the let-down reflex in breastfeeding.Collaborative Suggest use of mild. Determine past successful coping mechanisms. . Express feelings of self-confidence and satisfaction with progress and adaptation being made. Building on strengths promotes self-esteem and enhances ability to deal with current situation. ACTIONS/INTERVENTIONS RATIONALE Independent Evaluate situational support and home assistance Home assistance is an essential element in used (e. duty nurses. The challenge of the crisis and disequilibrium associated with role transition. upkeep of the house and meals. NURSING DIAGNOSIS: FAMILY COPING: potential for growth May Be Related To: Sufficiently meeting individual needs and adaptive tasks. nonaspirin analgesics if Reduces discomfort and promotes relaxation necessary. Identify tasks leading to desired changes. Refer to healthcare provider if uterine or wound Further evaluation is needed to determine the discomfort is excessive. stress.. allows client to and of the newborn. Encourage client to allow conserve energy for physical and emotional others to take on responsibilities related to recuperation. cause of discomfort and appropriate interventions. child into the family. enabling goals of self-actualization to surface Possibly Evidenced By: Family member(s) moving in direction of health-promoting and enriching lifestyle DESIRED OUTCOMES/EVALUATION Verbalize gradual improvement and smooth CRITERIA—CLIENT/FAMILY WILL: transition of new family member into home situation. friends.

Financial needs may necessitate use of protein sources other than meat. because of the potentially overwhelming transition required. risk for less than body requirements Risk Factors May Include: Intake insufficient to meet metabolic demands/correct existing deficiencies (e. vitamin C is necessary for cell wall synthesis.Evaluate family structure and situation. Blended family resulting from remarriage may relationships of individual members to one require a longer period of adaptation and present another.. intake of special foods (e.. member. desire to regain prenatal weight) Possibly Evidenced By: [Not applicable. make changes and to continue positive adjustment to new appropriate referrals. calories.g. Cultural practices may dictate and cultural beliefs/background. However. roles. anemia/excessive blood loss. Note: Folk beliefs/rituals/customs may dictate who provides assistance for client/family. Extended families may provide added physical and emotional support if available. cultural preferences. Provide anticipatory guidance related to the time Period of stress associated with adjustment to the birth needed to adjust to the new situation and family of a newborn is often resolved in 4–6 wk. ACTIONS/INTERVENTIONS RATIONALE Independent Determine dietary intake for past 24 hr. and cultural background. . history Identifies usual eating habits/deficiencies and of dietary habits prior to and during pregnancy. Calories considering constraints of family budget and are necessary for normal metabolic processes. this period may last as long as 3 mo. Helps correct deficiencies and inadequacies. especially for the underweight client. Protein Stress need for increased amounts (and food sources) is needed to promote tissue growth. May be necessary to help members resolve Discuss need for family counseling. Collaborative Refer to parent support group. infection/excessive tissue trauma. lactation. and of dietary protein. healing. Hmong people eat only chicken and white rice for 30 days postpartum). and vitamin C while regeneration and to offset catabolic process. Provide information regarding the basic food groups. when indicated.g. a more complex situation than a nuclear family. individual needs. presence of signs/symptoms establishes an actual diagnosis] DESIRED OUTCOMES/EVALUATION Report dietary intake that meets needs for CRITERIA—CLIENT WILL: lactation (as appropriate) and tissue healing/general physical restoration. Continue to take daily vitamin preparation as indicated. especially for adjustment to single parent. NURSING DIAGNOSIS: NUTRITION: altered.

the need for vitamin A. Display signs of wound healing and be free of purulent drainage. Review importance of fluid intake of 2500–3000 Necessary to support adequate milk production to ml/day for lactating client. Be free of infection. were during pregnancy. invasive procedures and/or increased environmental exposure. Determine caloric requirements for nonlactating Caloric requirements return to prepregnancy client and possible weight reduction diet. as needed. Suggest temporary use of ready-made convenience Demands of caring for newborn leave little time foods or having meals prepared by relatives. additional loss of approximately 5 lb usually follows over the next 2 wk. NURSING DIAGNOSIS: INFECTION. may result in pallor and listlessness. Intake needs to be increased by 500–800 kcal/day Identify foods that may have risk of allergic or to provide adequate milk production and infant other adverse effects on infant. friends. Provide illustrations/ utilization of calories while enhancing muscle demonstration as needed. unless client was severely underweight. meet infant’s needs as well as client’s own bodily needs. An postpartum weight. malnutrition Possibly Evidenced By: [Not applicable. decreased Hb. levels may retard healing process. calcium. Collaborative Consult with dietitian. Reduced Hb excess fatigue. and vitamin D are similar to those during pregnancy.Review prenatal Hb and Hct and the amount of blood Preexisting anemic state or excessive blood loss loss at delivery. Discuss dietary needs for the lactating client. Weigh client. risk for Risk Factors May Include: Tissue trauma and/or broken skin. Desired weight can be obtained by reducing caloric intake by 300 kcal/day and establishing an appropriate exercise program. Establish desired weight. ensure nutritious milk supply (as desired). May be necessary to plan and restructure diet to meet individual needs/restrictions. tone. Needs for iron. Some foods are passed through the mother’s milk and may cause discomfort or allergic reaction in the infant. thiamine. for preparation of balanced meals.. and Average weight loss at delivery is 10–12 lb. levels. can overcome dietary deficiencies. and aid in tissue healing. or significant other(s). Note signs of anemia (e. ascorbic acid. presence of signs/symptoms establishes an actual diagnosis] DESIRED OUTCOMES/EVALUATION Relate techniques to reduce risks and promote CRITERIA—CLIENT WILL: healing. Protein needs are 10 g less than they assessing infant’s discomfort. niacin. mainly compare with prepregnancy and initial attributable to infant and products of conception. Identify ways of nourishment.g. Provide information regarding progressive Exercise increases metabolic rate and improves postpartal exercise program. as indicated. and riboflavin increases. dizziness. and pallor). . Provide information about need for daily intake Iron and vitamin intake for 4–6 wk postpartum of vitamin and iron preparation.

Assess for. zinc strengthens cell membranes. . air drying of nipples. problems. exudate. Breast care reinforce information regarding breast and nipple measures help toughen nipples. May indicate cystocele and the need for further evaluation or surgical repair. Note presence of risk factors such as delivery These factors may predispose the client to UTI trauma. excessive blood loss. carbohydrates. UTI UTI requires prompt evaluation and intervention (e. Evaluate client’s hygiene practices. noting These factors increase risk of endometritis or other prolonged labor. carbohydrates are necessary to spare proteins. to prevent further involvement and complications. and pain in suprapubic region or costovertebral angle). and chills suggest infection. Instruct in use of appropriate muscle-tightening Exercise strengthens and tones perineal and exercises (e. or use of indwelling catheter during hospital stay. Determine whether infant was colonized with Increases risk of cross-contamination. zinc and vitamins A. amounts of food rich in protein. reducing risk of irritation/infection. Discuss dietary practices. and C. vitamin C is needed for cell wall synthesis. B-complex. vitamin A supports differentiation and cell proliferation. infectious process. especially to staphylococci in the nursery. premature rupture of membranes.g. Stress need for Identifies practices that could contribute to washing hands before and after perineal pad development of infection. Note redness. moisture. carbohydrates. prevent skin care. and limit presence of and need to avoid use of plastic-lined nursing pads. malaise. assess client’s general Temperature greater than 100. lactating clients. vitamin B enhances metabolism of proteins.g. amount. incision. Discuss use of creams. Note color. and Endometritis may be associated with character of lochial flow. urethral muscles to improve control of urine flow and reduce risk of infection. or loss of tissue requiring further evaluation/intervention. urgency. and stimulates epithelialization.ACTIONS/INTERVENTIONS RATIONALE Independent Check vital signs. dysuria. Assess nipples for cracks or fissures. Provide or Identifies potential source of infection. retention. changes and before handling breasts or infant. hematuria. malnutrition.4°F (38°C). diabetes.. Assess height of fundus. approximation.. Iron iron. is used for Hb synthesis. subinvolution or with presence of foul-smelling or purulent lochial flow. and review signs and symptoms of. and lipids. general physical status. anorexia. Kegel exercise). or retained/adherent placenta. breakdown and cracking. Note reports of stress incontinence. fever. frequency. Inspect site of episiotomy repair or cesarean These signs indicate presence of infectious process. previous UTI/renal following delivery. Review intrapartal and postpartal events. Stress need for increased Protein helps in tissue growth and healing.

NURSING DIAGNOSIS: ROLE PERFORMANCE. For example. ACTIONS/INTERVENTIONS RATIONALE Independent Determine family structure and individual The ease with which each family member adapts to expectations. as indicated. changes in responsibilities of family members) Possibly Evidenced By: Change in usual patterns or responsibility. wound drainage. Antimicrobial agent whose selection is based on culture and sensitivity findings helps eradicate pathogenic bacteria. Begin to set realistic goals. the blended family may create special concerns. produces more acidic with cranberry or orange juice. conflict in roles DESIRED OUTCOMES/EVALUATION Verbalize awareness of role expectations and CRITERIA—CLIENT WILL: potential problems. the new role and accommodates the new member may be influenced by the size.Test urine pH. Leukocytosis during initial 10–12 days postpartum is a normal protective mechanism associated with an increase in neutrophils and a shift to the left and must be distinguished from an abnormal finding indicating infection. especially WBC count. whereby the newborn is a half- brother or half-sister. Obtain cultures of lochia. May be needed for persistent symptoms. or failure to respond to antimicrobial agents. or urine as indicated. especially Helps prevent urinary stasis. urine reducing adherence of bacteria to bladder wall. Although all members of the family are to some extent influenced by the transition. cystocele. Collaborative Assess laboratory results. Discuss antibiotic administration. Talk with family members about situation and changes that have occurred. the client herself often suffers the greatest impact in terms of personal and professional responsibilities and must make the most significant accommodations and sacrifices in terms of her time and energy. Alkaline urine increases potential for bacterial growth. stability. Encourage client to increase fluid intake. Confirms presence of infection and identifies type. and complexity of the family. nipple discharge. . altered May Be Related To: Situational crisis (addition and demands of new family member. as appropriate. Refer for urologic consultation.

unfulfilled with the mothering role may have Encourage open communication and sharing difficulty adapting. Aid client in setting realistic goals and expectations Too much activity and unrealistic goals compound for herself. Assist client in acquiring skill and comfort in Client who is having difficulty or feels awkward feeding and bathing infant. Four weeks may be required for organizations). Dress comfortably. provide information about Sufficient time is required to select safe and potential sources and ways of evaluating child appropriate resources that will meet individual care providers. Initiate progressive. La Leche League. providing care may believe that she is failing in her mothering skills. NURSING DIAGNOSIS: BODY IMAGE disturbance May Be Related To: Unrealistic expectations of postpartum recovery. permanency of some changes Possibly Evidenced By: Verbalization of negative feelings about body. Report acceptance of self as she is at this moment.Evaluate individual and family goals and Client who feels cheated. feelings of helplessness. well. needs and allow client to return to personal and professional activities. Set realistic goals for change. Collaborative Refer client to visiting nurse services or community Client may need additional assistance in home support groups (e. Identification of problems can be helpful in reaching solutions that are compatible for all concerned. fatigue and reduce energy levels needed for coping and role integration. ongoing prescribed exercise program. disappointed. families to integrate infant care into their patterns of daily living. or client’s perception of new family situation. Reinforce client’s successes at mothering and Client’s self-confidence may be tenuous. Further intervention may be needed to promote positive individual and family adjustment. preoccupation with change. . she may specific accomplishments of individual family need constant assurance that she is performing members. Discuss concerns. as may the mother who is of feelings and concerns among family members.. focus on past appearance. fear of rejection/reaction by others DESIRED OUTCOMES/EVALUATION Verbalize realistic perceptions of new body CRITERIA—CLIENT WILL: contours. Recognition of efforts of those involved supports ongoing change and participation in problem solving. Refer for professional counseling. forced to return to work for economic reasons but would prefer to remain at home. step-family adjustment.g.

her. day up to 1 wk postpartum is continued thereafter. nevi. whose primary focus may be dating or reentry into a heterosexual relationship. . calories in the lactating mother results in inadequate milk production.. and poor body image. which may enhance her feelings of unattractiveness. changes in condition of hair and fingernails. Discuss ways of dressing attractively and the Attractive. Collaborative Refer to support groups. The adolescent. Recommend avoidance of emotional feelings may prevent him from making jokes or negative comments regarding her weight comments about her body that could reinforce and appearance. integumentary and musculoskeletal changes. increased foot growth. gained in excess of 24 lb (11 kg). which must be lost Discourage dieting in the lactating client until through proper diet and exercise. The client who and childbirth created. Encourage male to express caring negative feelings. palmar erythema. as indicated. Client may misinterpret the through increased time and attention or small gifts male’s focus on the newborn as lack of interest in such as flowers and cards. Coarse hair. may experience even greater difficulty adapting to. particularly for the emotionally immature client who places much emphasis on appearance. linea nigra. and coping with. The client may actually grieve the loss of her prepregnancy appearance. a new body image. fine hair growth. or for counseling as needed. and so forth. hairdresser. nonmaternity clothes and importance of taking time for personal appearance new hairstyle enhance self-esteem and feelings of with application of cosmetics. review ideal weight. has fantasized or imagined that she would resume her pregravid appearance and body contours following delivery may be depressed or disappointed when this has not occurred. Approximately 6 wk is required for abdominal wall and uterus to return to prepregnancy state. follow-up with May be necessary to resolve conflicts of self-esteem community resources. and joint hypermobility usually disappear or return to pregravid state.g. A potential crisis exists. Evaluate client’s normal physical activity level and Involvement in physical activities aids client in participation in sports or exercise program. Restriction of she stops breastfeeding. and spider nevi may not regress completely postpartum. trips to the attractiveness. areolar hyperpig- mentation. Provide information about postpartal exercises Regular exercise program that is specific for each (e. and discuss The client retains approximately 60% of weight proper nutrition as the key to losing weight. Weigh client. Provide information honestly regarding Chloasma.ACTIONS/INTERVENTIONS RATIONALE Independent Determine perception of new body image and Client’s self-esteem and adaptation to body image of actual or imagined changes that pregnancy are influenced by her perceptions. to trim figure and increase muscle tone. Ascertain male partner’s perception of client’s Helping male partner become aware of the client’s physical appearance. lifting hips off bed) or sleeping on abdomen. loose-fitting. regaining both a positive self-image and her pregravid shape.

NURSING DIAGNOSIS: FLUID VOLUME. Determine A history of problems with evacuation or presence of hemorrhoids. coffee. encourages general relaxation. promote enemas. and roughage promotes soft formed in roughage. delivery. and prevent fecal impaction. Review role of client’s current intake and the role Lack of roughage and inadequate fluid intake of fluid and diet in stool formation and evacuation. Provide information regarding the use of sitz promotes healing. resulting in dry. decreased physical activity. especially after the dilating and relaxing effects of progesterone experienced during the prenatal period. CRITERIA—CLIENT WILL: ACTIONS/INTERVENTIONS RATIONALE Independent Discuss normal evacuation pattern. fruits. active vascular loss (retained placental fragments) . perineal trauma. as appropriate) and diet high fruits/juices. and enhances sense of well-being. and vegetables. Note: Laxatives are not recommended for lactating clients. Note: Some cultures limit activity following delivery for a prescribed period of time. including daily Activity enhances muscle tone. and supports client self-care. reduce peristaltic motion of fecal matter through intestine. or constipation may contribute to problems following third-degree lacerations. stool. risk for Risk Factors May Include: Inadequate fluid/fiber intake. associated with evacuation. Recommend regular exercise. Helps prevent straining and reduces pain if appropriate. hard stools. Warmth from sitz bath helps relax anal sphincter. stimulates walking program. and reduces discomfort associated with evacuation. baths 3–4 times daily. Encourage adequate fluid intake (including Use of warm beverages (hot water. Assess healing of episiotomy or lacerations. May be necessary to stimulate peristalsis. risk for deficit Risk Factors May Include: Increased fluid needs/inadequate intake. eases evacuation. Collaborative Encourage continued use of stool softener. presence of signs/symptoms establishes an actual diagnosis] DESIRED OUTCOMES/EVALUATION Re-establish usual/optimal evacuation pattern. pain on defecation Possibly Evidenced By: [Not applicable. lactation needs. or suppositories. evacuation. Provide information regarding use of laxatives. peristalsis. tea). thereby increasing water reabsorption. NURSING DIAGNOSIS: CONSTIPATION.

presence of signs/symptoms establishes an actual diagnosis] DESIRED OUTCOMES/EVALUATION Demonstrate fluid balance as evidenced by CRITERIA—CLIENT WILL: adequate urine output.) Review client’s activity level. Collaborative Obtain screening Hb/Hct and compare with Provides comparative readings to assess severity levels obtained prior to discharge (if done). Brisk. A return to bright red bleeding is abnormal. procedure such as surgical D & C may be necessary to determine severity of condition. hemorrhage or dehiscence.2 mg PO every foster passage of retained placental tissue if BP is 3–4 hr for 1–2 days. Provide information regarding medications such as Used to promote uterine contractility. To identify delayed healing and the potential for note healing. dry lips/mucous membranes. as needed. Decrease in BP and increase in pulse may reflect hypovolemia. and dark/strong urine. Slight increase in flow may be secondary to inadequate rest associated with periods of increased activity. moist mucous membranes. Determine fundal height and note character and Failure of the fundus to involute properly (should amount of lochial flow. Display scant lochial flow that is brownish pink in color (serosa) and is free of clots following vaginal delivery. Hypovolemia may result in orthostatic changes. or of blood loss. (Refer to CP: Postpartal Hemorrhage. Note condition of skin. ACTIONS/INTERVENTIONS RATIONALE Independent Ascertain frequency of voiding and character Declining frequency/amount. Note reports of excessive fatigue or dizziness. Assess BP and pulse. presence of of urine. Possibly Evidenced By: [Not applicable. as necessary. Hb/Hct should return to normal with prenatal levels. within 3 days postpartum. good skin turgor. vital signs within normal limits. which may methylergonovine (Methergine) 0.5 mg of Hb. be located at the symphysis pubis) is associated with increased vaginal flow. (Each milliliter of blood lost contains 0. or to diagnose/correct problem. Hb should not drop more than 2 g/100 ml unless blood loss is excessive. Assess condition of perineum or cesarean incision.) Notify healthcare provider and prepare client for Repeat laboratory studies or more invasive additional evaluation/intervention. below 140/90. and poor skin turgor suggest inadequate fluid intake in relation to fluid needs. lips. mucous membranes. heavy flow indicates late postpartal hemorrhage secondary to retained placental fragments. .

household maintenance frees the client to devote her psychological energies to herself and infant. and awareness of the normalcy of these feelings may offset excessive self- concern or self-preoccupation. temporary family disorganization and role changes. presence of signs/symptoms establishes an actual diagnosis] DESIRED OUTCOMES/EVALUATION Identify individual stressors. and isolation are common. available and presence of realistic problem-solving coping mechanisms. coping mechanisms. weaknesses. Assess psychological status and discuss normalcy The fourth trimester. perceptions and the ability to respond appropriately to stressors. and situational support. . depression. because the client is vulnerable to negative feelings during crisis resolution and adaptation to stress. positive adaptation. Perhaps owing to unrealistic perceptions. depends on realistic perception of events. Assist couple with identification of anticipated Emotional disorganization associated with crisis is and unanticipated stressors and formulation often accompanied by distortion of cognitive of realistic problem solving. Determine individual stressors for client/couple. The degree of individual and family stress Note strengths. be manifested by real or imagined physiological symptoms. NURSING DIAGNOSIS: FAMILY COPING: ineffective. is a difficult period. Negative feelings of anxiety. especially in the primipara. Verbalize resources within themselves to deal with the transition. first-time parents tend to experience the greatest degree of crisis. may physiological state. Lack of balancing factors results in continued state of disorganization and persistence of crisis state. CRITERIA—CLIENT/FAMILY WILL: Set realistic goals and expectations. and problems with adjustment. little support provided by client for partner/family members Possibly Evidenced By: [Not applicable. “balancing” factors help facilitate quick resolution of problems. Crisis capabilities. Recognize need for and use outside support appropriately. and growth for client/couple and family. approximately 3 mo following birth. ACTIONS/INTERVENTIONS RATIONALE Independent Evaluate client’s actual and perceived Negative feelings. disintegration. Assess available means of assistance with Assistance with physical labor needed for housework and meal preparation. risk for compromised Risk factors May Include: Situational/developmental changes. a transitional period lasting of negative feelings in the client/couple.

and ineffective coping. disequilibrium. necessitating immediate intervention. especially if existing support systems are inadequate for the postpartal mother. May need additional assistance if existing support counselor. . continued crisis exists. Collaborative Refer client to appropriate community agency. Provide telephone contact number for 24-hr access. systems are inadequate or not available. or social services. New mothers (regardless whether first or fifth child) need access to healthcare resources early in the postpartal period and thereafter to facilitate adaptation.Assess for maladaptive behaviors or Potential for maladaptation.