Student’s Name: Deandra Maggs Date of Care: 3-27-21

YOUNGSTOWN STATE UNIVERSITY

NURS 3731: Childbearing Family and Women’s Health Nursing

POSTPARTUM HEALTH ASSESSMENT

Client’s Initials: K.S. Age: 30 LMP: 6-21 EDD: 3-26-21 Marital Status: Married

Gravida: 1 T: 1 P_______A_______L: 1

Delivery Date: 3-26-21 Time: 13:40 Postpartum Day: 1

Blood Type / Rh: A / + RhoGAM: YES / NO Breast or Bottle Feeding

If applicable, describe how labor was augmented or induced: N/A

Type of Delivery: Spontaneous Vaginal / Forceps / Vacuum Assist (Circle)

Episiotomy: Type N/A Lacerations: 2nd degree

Length of: Stage 1 : 12hrs 2 ; 2hrs& 40 min 3 : 10 min

Boy / Girl – Birth Weight: 8 lbs 5 oz. Length: 20” APGAR: 9 / 9

Was pregnancy: Planned / Unplanned? Was birth control used? Yes / No

Type or method of birth control, if used: N/A

Prenatal Care: YES / NO Number of Prenatal Visits: 12

Significant antepartal, intrapartal, or postpartum history: N/A

Significant maternal medical history: Herpes Simplex Virus

Current Health Status: Healthy

_

Did she attend childbirth education classes? YES / NO

PHYSICAL ASSESSMENT NURSING DIAGNOSIS
(PRIORITIZE)
VITAL SIGNS
Temp: 97.4 Pulse: 72 Resp: 18 BP: 103/58
1. Risk for infection
OBSTETRICAL
Breasts: Soft
Fundus: -1cm below the umbilicus
Lochia: Pink and light 2. Risk for impaired tissue
integrity
Perineum: 2nd degree lacerations w/ repair

SKIN / FLUIDS
Skin: Dry / Cool / Clammy / Diaphoretic
3. Risk for disturbed sleep
Color: Consistent with genetic background /
pattern
Pale / Flushed / Cyanotic / Jaundiced
Turgor: Good / Fair / Poor Diaphoresis: YES / NO

PERIPHERAL – NEUROLOGICAL
LOC: Alert / Lethargic / Disoriented Upper Extremities: 4. Risk for constipation
Movement: Full movement & ROM
Strength: +5; Full strength and resistance
Sensation: Full sensations
___________________________________ Lower Extremities:
5. Risk for postpartum
Movement: Full movement and ROM
depression
Strength: +5; Full strength and resistance
Sensation: Full sensation
CARDIOVASCULAR NURSING DIAGNOSIS
(PRIORITIZE)
Apical: Regular / Irregular Rate: 72
Pulses: Radial: R 2+ L 2+ Pedal: R 2+ L 2+
Edema: Location / degree: 2+ edema in lower extremities
Varicosities: N/A 6. Risk for bleeding

Capillary Refill: < 3 seconds

RESPIRATORY / OXYGENATION
History of shortness of breath, smoking, allergies:
7. Risk for Orthostatic
Penicillin and Amoxicillin drug allergies
Hypotension
Respirations: Easy / Labored
Dyspnea: With activity / At rest -N/A
Cough: Non-productive / Productive NO cough
Breath Sounds: Clear / Diminished: R / L 8. Risk for injury
Harsh: R / L Rales: R / L Rhonchi: R / L Wheeze: R /
L Inspiration / Expiration

GASTROINTESTINAL / NUTRITION
Height: 5’6” Weight: 170lbs
9. Risk for anxiety
Pregnancy weight gain: 20lbs
Usual nutritional intake from Basic Food Groups: (give examples)
Has a good protein and carb intake. (eats many fruits, drinks
protein shakes, consumes lean meats).

Intake of alcohol, tobacco, caffeine, street drugs: 10. Risk for impaired Comfort

Drank caffeine before pregnancy daily

Adequate nutritional intake for breastfeeding, tissue repair:

Has adequate intake
 NURSING DIAGNOSIS
Abdomen: Soft / Firm / Distended / Tender
(PRIORITIZE)
Bowel Sounds: Normoactive / Hypo / Hyper / Nausea /
Vomiting
Bowel Movement since Delivery: None 11. Risk for caregiver role
strain
GENITOURINARY
Urine output: unmeasurable x4 voids
Difficulty voiding since delivery: burning sensation felt with
voids 12. Risk for ineffective role
performance
SLEEP / COMFORT
Sleep pattern: sleeps about 7hrs
Feel rested in AM? Yes Naps? Yes
Usual methods of coping with pain/discomfort:
Ibuprofen
PSYCHOSOCIAL HEALTH ASSESSMENT
Social Interactions:
Maternal-newborn attachment: Very close attachment

Relationship/interaction with her other children:

First-time mother = N/A

Relationship/interaction with father of newborn:

Very loving, kind, and compassionate
Support system: Good support system from family and
friends

Any changes in family relationships, support system,

home/work environment in the past year?
Denies any changes
If so, what and how have they affected her? N/A
 Interests/hobbies: enjoys learning, spending time with family NURSING DIAGNOSIS
and friends (PRIORITIZE)

Spirituality: Member of an organized religion?

Roman Catholic

How important is her religion/spirituality to her?

Important

Sense of Self:
Ethnic and cultural background: Italian and Slovak
How does her ethnic/cultural background influence health
behaviors? N/A
Occupation or previous employment history: OR nurse at
Southwoods

If employed, does she plan on returning to work? Yes

When? 12weeks

DEVELOPMENTAL HEALTH ASSESMENT

(Refer to article by Ramona Mercer on BB)
What is this mother’s stage of growth and
development which you identified from your
assessment data? (include data to support your
conclusions): _________________________________
_____________________________________________
_____________________________________________

Identify and define her expected stage of growth and

development?__________________________________
_____________________________________________
_____________________________________________
 Has this mother successfully accomplished the NURSING DIAGNOSIS
developmental tasks of pregnancy (include assessment (PRIORITIZE)
data)?___________________________________
_______________________________________

What does this mother think about her present

situation/circumstance? The mother is excited to have her
first child

How does this mother anticipate changes r/t herself: Says

d/t her healthcare background, she has an idea of what to
expect.

Changes R/T family dynamics: Having their 1st child

What questions does this mother have at this time?

Wanted to know if she could have some type of moist pad
for her perineum. Notified her nurse.

What could you do to facilitate her growth and

development? Teach about ways to prevent pain from
perineal lacerations.

What are the educational needs for this mother to

care for herself, her newborn, and family?
Safe newborn sleep, breastfeeding techniques, perineal
care

Social Support Services (if applicable) N/A

Test Parameter Test Result Probable Cause Nursing Action
1. No drug usage
1. Urinalysis 1. Positive 1. None 2. Normal 1. Inform
drug or detect 3. Slightly low results
screen negative ed but still WDL 2. Inform
2. Hgb 2. 11.7-15. 2. 11.8 4. Normal results
3. Hct 5 3. 35.2 finding 3. Monitor
4. Rubella 3. 35%-45 4. 1.93 5. Normal results
5. Urine % 5. Negati finding that frequently
glucose 4. 0.9-0.99 ve indicates no 4. Inform
6. Urine 5. Positive 6. Negati gestational client of
protein or ve diabetes results
7. Pap Test negative 7. Negati 6. Normal 5. Teach about
8. Leukocyte 6. Negativ ve finding that maintaining
s e or 8. Negati indicates no a healthy
9. Nitrites Trace ve preeclampsia diet and
<300mg 9. Negati 7. Normal exercise
/d ve finding that 6. Teach about
7. Positive indicates no maintaining
or cell changes a healthy
Negativ on the cervix diet and
e occuring exercise
8. Positive 8. Normal 7. Patient
or finding that education
negative indicates no such as it is
9. Positive presence of normal to
or infection such spot/lightly
negative as UTI bleed after a
9. Normal pap test
finding during
indicates no pregnancy
presence of 8. Educate
bacteria in patient on
urine signs and
symptoms
of UTI
Colace

● Docusate Sodium
● 100mg b.i.d
● Stool Softener
● Commonly used for occasional constipation and prevention of straining. The mechanism
of action is it increases the amount of water the stool absorbs in the intestines.
● Nurses should monitor for a therapeutic response, stop giving if diarrhea, cramping, or
rectal bleeding occurs.
Iron

● Ferrous Sulfate
● 325mg b.i.d
● Supplement
● Used in cases of anemia or pregnancy where low h&h levels can occur
● Teach pt to expect a change in stool color, monitor BM for constipation, teach to continue
taking the supplement 2-3 months after hgb has returned to normal levels.
Pitocin
● Oxytocin
● 30units in 500ml
● Oxytocic Agent
● Mechanism of action is to cause uterus to contract to induce labor as well as control
bleeding after delivery
● Monitor maternal vitals, assess hydration/electrolyte status, assess fundus frequently.
Dermoplast
● Benzocaine-menthol
● Topical PRN
● Local Anesthetic
 ● In pregnancy, commonly used to reduce any pain or burning of perineal
lacerations/episiotomies. Also reduces the risk of infection. Can also be used for
hemorrhoids.
● Monitor pain levels, clean area before administrations, assess mucous membranes.
Motrin
● Ibuprofen
● 800mg q6hrs PRN
● NSAID
● Used to relieve mild to moderate pain and discomfort. Can reduce surgical incision
swelling for c/s.
● Should be administered with food. Do not take with antihistamines, tranquilizers, or
alcohol. Monitor for pain levels.
Epidural
● Bupivacaine
● 1-2mg bupivacaine with 5-15ug fentanyl given via catheter
● Local anesthetic
● Inhibits pain that is caused by uterine contractions by causing numbness from the
umbilicus to the upper legs in the mother where only pressure can only be felt, allowing
the mother to still feel when to push during delivery.
● Monitor maternal vitals. Assess for toxicity, hypotension, and urine output. Teach about
assistance with slow position changes. Teach that the pain will usually subside in about
15minutes.
Care Plan: Mom
Nursing Diagnoses Behavioral Outcome Nursing Interventions Documented Rationales Evaluation,
Objectives (Cite) Modifications

-Patient will perform -Nurse will continue to -Patient education Patient

Risk of Infection a return educate patient on over hand hygiene is demonstrated
related to second demonstration of the proper hygiene pertinent because hand no elevated
degree perineal correct form of techniques washing can prevent body temp, no
lacerations perineal hygiene care infection by avoiding discolored or
-Nurse will continually pathogenic odorous
-Patient will remain assess for signs and microorganisms and discharge, no
free from signs and symptoms of infection avoiding transmitting increase in pain
symptoms if infection (increased body them (Lowdermilk, or swelling, to
temperature, color, Perry, Cashion, Alden, conclude no
-Patient will verbalize warmth, discharge, and Olshansky, 2016, p. signs of
the correct signs and odor, increase in pain 227). infection.
symptoms of and swelling).
infection and when to -Signs and symptoms
notify their healthcare -Nurse will analyze include localized
provider WBC results to swelling, localized
determine possible redness, pain or
infection tenderness, and
palpable heat
(Lowdermilk, Perry,
Cashion, Alden,
Olshanksy, 2016, p.
385).

-An increased WBC

count indicates the
body’s efforts to
combat pathogens.
(Lowdermilk, Perry,
Cashion, Alden,
Olshansky, 2016, p
382 ).
Care Plan: Baby
Nursing Diagnoses Behavioral Outcome Nursing Documented Rationales (Cite) Evaluation,
Objectives Interventions Modifications

Risk for -Infant will maintain -Nurse will safely -”Newborns lose body heat Newborn
ineffective body temperature wrap newborn through conduction, demonstrated
thermoregulation within normal range evaporation, convection, no signs and
r/t immature -Nurse will teach and radiation” (Lowdermilk, symptoms of
compensation for -Infant will show no mother how to Perry, Cashion, hypothermia.
changes in the evidence of chills safely wrap Alden,Olshansky, 2016, p Maintained a
environmental newborn 436). body
temperature -Infant will remain temperature
safely wrapped to -Nurse will -”Monitoring axillary within normal
maintain body monitor axillary temperature is an accurate limits.
temperature temperature way to determine and
regularly prevent altered body
temperature” (Lowdermilk,
-Nurse will place Perry, Cashion, Alden,
newborn in Olshansky, 2016, p 436).
warmer PRN
-”Incubators and radiant
-Nurse will teach warmers are used to
mother the signs maintain the body
and symptoms of temperature of newborn
hypothermia and infants” (Lowdermilk,
ways to prevent it Perry, Cashion, Alden,
Olshansky, 2016, p 436).
-Nurse will teach
mother effective -”Patient education of signs
skin-to-skin and symptoms of
methods hypothermia prevents
further loss of body heat
(Lowdermilk, Perry,
Cashion, Alden, Olshansky,
2016, p 437).

-”Skin-to-skin stabilizes
newborn’s body
temperature, respiratory
rate, heart rate, and blood
glucose” (Lowdermilk,
Perry, Cashion, Alden,
Olshanksy, 2016, p 325).
 Evaluation

This mother underwent a spontaneous vaginal delivery. Pain management such as an

epidural and motrin was provided during and after delivery. The patient had a second degree

perineal laceration that was repaired with vicryl and chromic sutures. As pain relief for the

lacerations, the mother stated she frequently uses dermoplast for relief. The mother was

monitored closely by her nurse and her fundus was checked regularly for any signs of a possible

hemorrhage. Due to the patient being a first-time mother, patient education was highly important.

The mother received education over topics such as breastfeeding and safe sleep while I observed.

The baby boy was delivered at 13:40 and was a healthy 8lbs 5oz. His APGAR score was a 9/9.

The newborn received his vitamin K injection and erythromycin ointment when first delivered.

The baby seemed to be eating well and voiding sufficiently. The parents were waiting for the

baby to be scheduled for his circumcision this night of care. Overall, I believe the care that was

given to this mother and her baby was satisfactory. Her pain levels were kept low and the nurse

made sure to take every opportunity for patient education. I feel that patient education is

extremely important, especially on a postpartum unit.

The one thing I wish I did differently when caring for this family is to not be as nervous

in my communication skills. I wish I appeared more personable to the family and less anxious. I

am working on controlling my anxiety in order to perform the best possible care for my patients

in the future.

If I was the nurse for this mother, I would understand that patient education for a

first-time mother is key. Since the mother is breastfeeding, I would educate her on the different

positions to hold the baby and have them latch on, the benefits of colostrum, and ways to prevent

infections such as mastitis. I would also explain how to prevent her perineal lacerations from
infection and ways to relieve pain when voiding. I would discuss with the family the importance

of rest and a strong support system.

In regards to discharge planning, I asked the mother if she had intentions of going back to

work. She said she was planning on returning to work at her surgical nursing job in twelve

weeks. I asked about care for the newborn once she returned to work and provided her with child

care services. I would screen her for any risks of postpartum depression. I would ask about her

support system. I would notify her about proper forms of birth control and to refrain from sexual

activity until she gets approval from her doctor. I would emphasize the importance of safe sleep

and SIDS prevention. From this experience the major thing I learned was all the diagnostic tests

a woman undergoes during pregnancy. It was interesting to look up all of the tests and normal

ranges and what an abnormal result can indicate.