N3731 Course Packet 1

Student’s Name: Danielle Pelini Date of Care: 09/25/18

YOUNGSTOWN STATE UNIVERSITY

N3731: Childbearing Family and Women’s Health Nursing

POSTPARTUM HEALTH ASSESSMENT

Client’s Initials: MG Age: 29 LMP: 3/24/18 EDD: 9/24/18 Marital Status: Married

Gravida :1 T :1 P :0 A :0 L :1

Delivery Date: 9/24/18 Time: 9:50AM Postpartum Day: 9/25/18

Blood Type / Rh: AB+ / Neg RhoGAM: YES / NO Breast or Bottle Feeding (Underline)

If applicable, describe how labor was augmented or induced: Induction secondary to preeclamipsia

without severe features.

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

Episiotomy: Left vaginal wall laceration and second-degree midline laceration performed in running

fashion.

Length of: Stage 1: 6 hours 2: ~1 hour 3: 20 minutes

Boy / Girl – Birth Weight: 7 lbs 2 oz. Length: 22inches APGAR: 9/10

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: ~10-15

Significant antepartal, intrapartal, or postpartum history: Intrapartal infection and preeclampsia without

severe features.

Significant maternal medical history: None on file

Current Health Status: Good Health

Did she attend childbirth education classes? YES / NO

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PYSICAL ASSESSMENT
VITAL SIGNS
Temp: 98.7 Pulse: 108 Resp: 16 BP: 159/75

OBSTETRICAL
Breasts: WDL. Soft with nipple integrity intact. Breastfeeding bra on. Using warm and cold
compresses, breast pump, nipple shield, nursing pads and using breast shells.
Fundus: Firm at midline. Two fingerbreadths below umbilicus.
Lochia: Minimal. Light pink. No pooling or clots present.
Perineum: Dry and intact without discharge or hematoma.

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 ROM
Strength: Strong
Sensation: Full
Lower Extremities:
Movement: Full ROM
Strength: Strong
Sensation: Full
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CARDIOVASCULAR
Apical: Regular / Irregular Rate: 108
Pulses: Radial: R +2, L +2 Pedal: R +2, L +2.
Edema: Location / degree: +1 RLE and LLE, Trace upper extremeties.
Varicosities: None
Capillary Refill: < 3 seconds.
RESPIRATORY / OXYGENATION
History of shortness of breath, smoking, allergies: None
Respirations: Easy / Labored
Dyspnea: With activity / At rest: None
Cough: Non-productive / Productive: None
Breath Sounds: Clear / Diminished: R / L
Harsh: R / L Rales: R / L Rhonchi: R / L
Wheeze: R / L Inspiration / Expiration
GASTROINTESTINAL / NUTRITION
Height: 5’3” Weight: 202lbs
Pregnancy weight gain: 30lbs
Usual nutritional intake from Basic Food Groups: (give examples): Pt. states her diet consists mostly
of lean meats paired with fruits and vegetables. An example of a breakfast she often eats would be
a quick bowl of oatmeal and a banana before work and a coffee. An example of a lunch she often
eats would include chicken, rice, and green beans. The new mother says she tries to stay away from
snacking and is kind of a freak about her diet. Especially since becoming pregnant.
Intake of alcohol, tobacco, caffeine, street drugs: Drinks coffee in the mornings and has occasional
glass of wine at night. During lactation mom should avoid smoking, alcohol, and too much caffeine.
Adequate nutritional intake for breast feeding, tissue repair: Similar to pregnancy, it’s important
That mom consumes at least 1800kcals/day when she is breastfeeding. She should also have adequate
fluid intake.
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Abdomen: Soft / Firm / Distended / Tender

Bowel Sounds: Normoactive / Hypo / Hyper / Nausea / Vomiting
Bowel Movement since Delivery: No. Given Colace on DOC.

GENITOURINARY
Urine output: Daily total 46.25ml
Difficulty voiding since delivery: None

SLEEP / COMFORT
Sleep pattern: Interrupted during pregnancy. Normal now.
Feel rested in AM? Yes/No Naps? Yes/No
Usual methods of coping with pain/discomfort: Pt. uses relaxation
techniques such paced breathing, distraction, and comfort positioning.
She is also given medications for pain relief.

PSYCHOSOCIAL HEALTH ASSESSMENT

Social Interactions: Father/husband present during recovery. Pts
parents and other family have already been by to see the baby. All
of the focus seems to have shifted toward the baby.
Maternal-newborn attachment: Pt bonding with the baby through
skin-to-skin contact, breastfeeding, eye contact, and newborn
massage. She started this during the first hour of postpartum.
Relationship/interaction with her other children: No other
children.
Relationship/interaction with father of newborn: Married to
father of newborn. Father was present for labor and recovery.
Support system: Mother, Father, Husband and his family. Pt states
she has many friends who have also been supportive and happy
for her.
Any changes in family relationships, support system,
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home/work environment in the past year? None. Currently works as

nurse in ICU at St. Joes in Warren.
If so, what and how have they affected her? N/A
Interests/hobbies: Working, spending time with family and friends.
Spirituality: Member of an organized religion? Catholic
How important is her religion/spirituality to her? Very important
but it’s “more of a personal thing.”
Ethnic and cultural background: Asian
How does her ethnic/cultural background influence health
Behaviors? Patient states that it doesn’t. She said since she’s a
Nurse so a lot of her influences come from her education.
Occupation or previous employment history: ICU nurse at
St. Joes in Warren, Oh.
If employed, does she plan on returning to work? Yes
When? Pt states she’d like to go back as soon as the doctors will let her,
but the time off will be nice now that the baby is here.

DEVELOPMENTAL HEALTH ASSESMENT

(Refer to article by Ramona Mercer)
What is this mother’s stage of growth an development which you
identified from your assessment data? (include data to support your
conclusions): The patient is currently in the “commitement,
attachment and preparation” stage. The mother is making psychological
adjustments and is preparing for the expectations of her new role as a
mother. The patient had a lot of questions for the nurse so that she
could “provide the best care possible for her baby boy.”
Identify and define her expected stage of growth and development?
The mother is expected to complete all stages of growth and develop-
ment as evidence by her motivation to start taking on her motherly
duties.
Has this mother successfully accomplished the developmental tasks of
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pregnancy (include assessment data)? Yes. She is already experience

maternal-fetal attachment and she is giving herself to the demands of
being a mother. She states she has willingness and will put forth effort
to make personal sacrifices for the child if need be.
What does this mother think about her present situation/
circumstance? Pt. states that she is excited and so happy that the
baby is finally here, but a little nervous to be a new mom. She’s having a
little bit of conflicting feelings about this new role. Not that she is
regretting her decision, but that it’s just a lot to adjust to.
How does this mother anticipate changes r/t herself: Pt states that
They will have to shift her focus to their newborn. This is their first
Child so a lot of things are going to be different.
Changes R/T family dynamics: Not only is she a new mom. Her
Husband is a new father. They are both embracing their new roles.
What questions does this mother have at this time? “When can I go
home?
What could you do to facilitate her growth and development? I was able
to put on a postpartum video for her that answered any questions she
did have at the time that the physician and other health care providers
did not cover.
What are the educational needs for this mother to care for herself,
her newborn and family? Patient is currently very educated. Works as
a nurse and is still very familiar with the education.
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

Magnesium 1.6-2.6mg/dl 6.2 (high) Hypermagnesemia Monitor labs for

r/t preeclampsia electrolyte disturbance
and further changes.

AST 0-31U/L 38 (high) Dec. tissue perfusion Monitor liver fxn

to liver, homeostasis levels.
and recovery.

Bleeding r/t Monitor for excessive

Hemoglobin 11.5-15.5g/dL 12.6 laceration, blood loss bleeding, fluid volume
Pre 10.3 (low) during labor. defecit. Assess
Post laceration and monitor
for pooling/clots.

CO2 22-29mmol/L 20(low) Hyperventilation; Position of optimal

Respiratory alkalosis. comfort for breathing
Medications. Dec. and oxygen echange.
tissue perfusion.

Slight gestational Monitor blood glucose

Glucose 74-109mg/dL 119 (high) diabetes; level. Only slight
Hyperglycemia. elevation. Discuss
Dehydration; Diet. diet.

Intrapartal infection.
Blood in Urine Negative 30 Preeclampsia Risk for infection
protocols. Hygeine
Bacteria UA Negative Few! Intrapartal infection and perineal care.

Blood pressure 140/80 133/92 Preeclampsia; HTN Medicate, Stress and

pain control. Monitor
BP
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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.

Colace 2x/day, ferrous sulfate 3x/day, magnesium sulfatex1, lactated ringers in dextrost 5% cont.,
Morphine PRN, Pitocin induction.
(Medication Sheets Attached)

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

Giving birth is exhausting, and the newborn is not the only one who needs to be taken care of following the birth.
The woman needs to be in a stable condition because immediate postpartum is a critical stage for both the woman and her
baby. The woman’s body is adjusting to not being pregnant anymore (homeostasis) and the baby is no longer receiving
oxygen and nutrients through the placenta.
The postpartum patients emotional status plays a significant role in her recover and her adjustment to hew new baby.
The hospital stays are brief, so we as nurses need to have a meaningful encounter with our patients. We’ve developed a
systematic method of assessing the patient and have allowed us to save time and allow for quicker identification of patient
needs. The aspects of the patient’s psychological status that are assessed include the patient’s reaction to the birth experience,
the pts. adaption to the infant and the family reaction to the infant.
As nurses, we would assess the woman’s pregnancy history, especially if the pregnancy was planned or unplanned.
That might determine the ability of the woman to bond with the newborn. Other things are closely monitored. This includes
activity level after birth, difficulties or pain felt and whether or not she is having trouble feeding. This anticipates whether or
not guidance in home care will be needed.
Nurses should also be looking at laboratory data to assure the woman is recovering well. This and that no additional
diagnostic tests or procedures need to be performed. We can rely on the technology completely though. We would have to
assess the woman’s general appearance because it is a reflection of how well the women is moving into the taking hold phase
of recovery. In a patient like mine, with pregnancy induce hypertension we would check out her face for facial edema. This is
an abnormal finding.
For further assessment we would examine the woman’s breasts for any cracks or fissures, and assessed for mastitis
such as inflammation of a certain part of the breast. Moving on, we assess the location, consistency, and height of the fundus
through palpation. If it is not firm, we would massage it gently. Lochia is expected in postpartum for about 2 to 6 weeks. It’s
characteristics are assessed. We should not see pooling or clots.

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.

On the day of care I was able to do a full post partum assessment on my patient. If I could go back and do something
different, I would have come a little more prepared with specific information and advice that would be helpful in teaching the
mother about safe care for her infant when she leaves the hospital. The nurse I was observing had a lot of good advice being a
mother herself and such an educated nurse.
It’s important that we make sure that before women are discharged, that they are educated properly. Regarding the
care of the newborn and themselves at home once they leave the hospital. We are continuously assessing the ability of the
mother and father if present to absorb new instructions and to listen. We have to consider there is a lot going on for them at
the moment.
As their primary nurse I would suggest group classes regarding newborn care. It could help mothers learn not only
what the instructors teach but learn from the experiences that some mothers share to the group. I would also encourage the
father to attend classes and engage in learning proper care. This would make it so the mother would have someone she could
rely on with newborn care and promote coparenting. Individual instruction is also sought after postpartum, as the family will
need to know how to care for the woman and the newborn after discharge. Teaching doesn’t always have to be formal. It can
be comments during videos or procedures.
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There are things that these women need to know before they leave like to avoid lifting heavy objects for the first
three weeks and allowing a rest period everyday or to rest and sleep while her newborn is also asleep so she can regain her
energy. I would also inform them that must return to the health care facility after 4-6 weeks for an examination and that the
baby needs to be examined by a pediatrician at 2-4 weeks of age.
As the primary nurse I would make sure that the woman and the family understood the discharge instructions. I
would review instructions with parents before they leave and make sure all questions are answered! Calling or visiting 24
hours after discharge is the best way to evaluate whether the family has been able to grasp all instructions and integrate the
newborn into the family. If I were to visit, I’d examine both the mother and the newborn physically to note any signs of
postpartum complications or defects.

REFERENCES (APA) FORMAT ONLY (Must include OB text, do not use care plan
books!)

Lowdermilk, D.L. (2016) Maternity and women’s health care (11th ed.). St.Louid: Mosby

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
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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 ___