N3731 Course Packet 1

Student’s Name:_Ian Hileman___________________ Date of Care: October 9th, 2018

YOUNGSTOWN STATE UNIVERSITY

N3731: Childbearing Family and Women’s Health Nursing

POSTPARTUM HEALTH ASSESSMENT

Client’s Initials TB Age 36 LMP 012/05/2017 EDD 9/12/2018 Marital Status Married

Gravida 3 ; T 2 P 1 A 0 L 2

Delivery Date: October 9th, 2018 Time: 01:23 Postpartum Day: 0

Blood Type / Rh: ___O / +__ RhoGAM: YES / NO Breast or Bottle Feeding (Circle)

If applicable, describe how labor was augmented or induced:

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

Episiotomy: Type second degree Lacerations Middle

Length of: Stage 1 6 hours 2 30 minutes 3 2 minutes

Boy / Girl – Birth Weight: __9__ lbs oz. 3 Length: 49.3 cm APGAR: 9 / 9

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

Type or method of birth control, if used: ____________________________________________

Prenatal Care: YES / NO Number of Prenatal Visits: 9

Significant antepartal, intrapartal, or postpartum history: amniotic fluid contained meconium; epsiotomy

(2nd degree lacerations)

Significant maternal medical history: None

Current Health Status: Healthy; Mild cramps. Good outlook

Did she attend childbirth education classes? YES / NO

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NURSING DIANOSES
PYSICAL ASSESSMENT
(PRIORITIZE)
VITAL SIGNS
Acute pain r/t postpartum
Temp 98.2 Pulse 82 Resp 16 BP 128/62
physiologic changes
(episiotomy)
OBSTETRICAL
Breasts Within defined limits
Fundus Firm fundus, location at umbilicus
Lochia Rubra, small amount, no odor, no clots
Perineum Well – approximated

SKIN / FLUIDS
Skin: Dry / Cool / Clammy / Diaphoretic
Color: Consistent with genetic background /
Pale / Flushed / Cyanotic / Jaundiced
Turgor: Good / Fair / Poor Diaphoresis: YES / NO

PERIPHERAL – NEUROLOGICAL
LOC: Alert / Lethargic / Disoriented
Upper Extremities:
Movement Full movement
Strength appropriate ; strong
Sensation full sensation

Lower Extremities:
Movement Full movement
Strength appropriate ; strong
Sensation full sensation
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NURSING DIANOSES
CARDIOVASCULAR
(PRIORITIZE)
Apical: Regular / Irregular Rate 82
Pulses: Radial: R +2 L +2 Pedal: R +2 L +2
Edema: Location / degree Non pitting
Varicosities: none
Capillary Refill: < 3

RESPIRATORY / OXYGENATION
History of shortness of breath, smoking, allergies: N/A
Respirations: Easy / Labored
Dyspnea: With activity / At rest
Cough: Non-productive / Productive
Breath Sounds: Clear / Diminished: R / L
Harsh: R / L Rales: R / L Rhonchi: R / L
Wheeze: R / L Inspiration / Expiration

GASTROINTESTINAL / NUTRITION
Height: 5’10” Weight 217
Pregnancy weight gain: estimated 30lbs
Usual nutritional intake from Basic Food Groups: (give
examples) Patient states that stayed on a diet with limited salty
food to reduce swelling; diet with meats, vegetables, and fruits

Intake of alcohol, tobacco, caffeine, street drugs: Pt reports to

never be a smoke/drug use, no alcohol use

Adequate nutritional intake for breast feeding, tissue repair: yes

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NURSING DIANOSES
Abdomen: Soft / Firm / Distended / Tender
(PRIORITIZE)
Bowel Sounds: Normoactive / Hypo / Hyper / Nausea / Vomiting
Bowel Movement since Delivery: No, taking Colace

GENITOURINARY
Urine output: -500 mL (24 hour output)
Difficulty voiding since delivery no

SLEEP / COMFORT
Sleep pattern: Trouble sleeping at night Sleep pattern disturbance
r/t excitement, discomfort,
Feel rested in AM? Yes Naps? Yes
and environmental
Usual methods of coping with pain/discomfort: Tylenol and warm interruptions
blankets

PSYCHOSOCIAL HEALTH ASSESSMENT

Social Interactions:
Maternal-newborn attachment: Mother holds baby by chest
and side, did not request to take baby back to nursery

Relationship/interaction with her other children: Involved in

childrens life. Makes sure they are well taken care of

Relationship/interaction with father of newborn: Involved in

childrens life. Makes sure they are well taken care of

Support system:
Any changes in family relationships, support
system, home/work environment in the past year? NO
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If so, what and how have they affected her? N/A

NURSING DIANOSES
(PRIORITIZE)
Interests/hobbies: Interested in reading and music

Spirituality: Member of an organized religion?

Member of Catholicism
How important is her religion/spirituality to her? Not so
important

Sense of Self:
Ethnic and cultural background: Caucasian women
How does her ethnic/cultural background influence health
behaviors? Cares about self-being; takes health seriously
Occupation or previous employment history: Manager for
fedex
If employed, does she plan on returning to work? Yes
When? 6 weeks

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): Stage: Acquaintaince and attachment to
infant, wants to see infant and learn how to take care
of infant. Responds to cues

Identify and define her expected stage of growth and

development? Mother displays sings of wanting to care
for the body and physical restoration of self
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NURSING DIANOSES
Has this mother successfully accomplished the (PRIORITIZE)
developmental tasks of pregnancy (include assessment
data)? Yes, she has completed takes of the development

What does this mother think about her present

situation/circumstance? Mother is excited to add a
new born to the family. Showing signs of acceptation

How does this mother anticipate changes r/t herself

Family is well prepared and ready to the newborn
mother understand that she will need to adjust sleep
cycles. Planning to return back to work.

Changes R/T family dynamics: N/A

What questions does this mother have at this time?

Mother and father both had no questions for me
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NURSING DIANOSES
(PRIORITIZE)

What could you do to facilitate her growth and

development? Provide the proper teaching to the patient

What are the educational needs for this mother to

care for herself, her newborn, and family? Mothers is
well educated, provided videos on shacking baby
syndrome and safe sleep

Social Support Services (if applicable) N/A

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DIAGNOSTIC TESTS: Describe diagnostic tests performed during pregnancy, labor & delivery, and
postpartum (i.e. x-rays, sonograms, lab, fetal monitoring, EKG, etc.).

Test Parameter Test Result Probable Cause Nursing Action

Urine drug Amphetamine Negative Mother is not a No action needed

screen Barbiturate drug user
Benzodiazepine
Cannabinoid
Cocaine
Opiate
PCP

Screen ABO/ Rh and O Pos Determine blood No action needed

antibody screen type blood type and
Rh factor are
compatible
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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.

Docusate sodium (Colace) capsule 100 mg

Acetaminophen (Tylenol) 650 mg. PO q4 hours PRN for pain

Tdap (Boostrix) injection 0.5 ml

NURSING CARE: Describe the nursing care, assessments, treatments and health education this mother
is receiving and explain why? What is the nursing role?

During the post-partum period as a student I assisted the nurse and we focused on assessment. The
nurse used the BUBBLE assessment and gave med accordingly. We also allowed as much time needed
to the family and gave them privacy during the bonding time

We showed videos for educational purposes. We showed the videos to the mother and father on ABCs
of sleeping and for Shaking baby syndrome. Then we educated them on all other possible learning
objective the family may have.

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, (3) what you would do for this expanding
family if you were the primary nurse form admission to discharge, (4) discharge planning, and (5) what
you learned from this family and from this clinical experience.
REFERENCES (APA) FORMAT ONLY (Must include OB text, do not use care plan books!)
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CRITERIA FOR EVALUATING

POSTPARTAL HEALTH ASSESSMENT & NURSING CARE PLAN

Planning Score
1. Goals: (2.5%) ______
a) Clearly identified nursing and client goals.
b) Were realistic.
c) Were written in correct format.
2. Objectives: (5%) ______
a) Measurable, realistic, and appropriate of the diagnoses.
b) Time frame for each objective included.
c) Individualized to the client.
3. Incorporated the educational needs of the client/family. (2.5%) ______

Assessment and Analysis

1. Completed maternal health assessment (25%) ______
a) Database was thorough and complete.
b) Demonstrated thorough analysis of health assessment data.
2. Nursing diagnoses were: (5%) ______
a) Accurate, correctly formatted/written, and prioritized.
3. Identified nursing diagnoses for actual or potential: (5%) ______
a) Physical health needs
b) Psychosocial health needs
c) Developmental health needs
d) Educational needs for care of newborn

Implementation
1. Nursing actions: (20%) ______
a) Were appropriate for the nursing diagnoses.
b) Included when/how often nursing actions were to occur
c) Included collaborative actions pertinent to medical orders.
d) Included independent nursing actions.
2. Documented rationales were: (20%) ______
a) Relevant to nursing diagnoses, nursing assistive actions, and objectives.
b) Accurate, thorough, and complete.
c) Correctly cited and referenced according to APA format.

Evaluation
1. Evaluation of nursing care: (5%) ______
a) Measured progress toward meeting each goal/objective.
b) Provided data to support progress toward attainment of objectives.
c) Specified modifications necessary for attainment of goals/objectives.
2. Documentation of professional self-growth: (10%) ______
a) Included summary and analysis of nursing care
b) Included what was learned from clinical experience.
TOTAL ___