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Postpartum Patient
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Postpartum Patient
30yo F pt G2P1 s/p C-section on 2/20 at 40w3d gravid
- Category II tracing and oligohydramnios led to C/S rather than vaginal birth
- First time parent
- Pt worried about baby feeding & voiding properly
- Deficient Knowledge
- r/t life role change
- AEB expression of worry regarding proper baby feeding and voiding habots
- Goal: patient verbally expressed relief of worry and demonstrates learning of teaching by the end of the shift
- Intervention (1): Consider the client's abilities and readiness to learn (Ackley 10th edition, p. 504). Rationale: If the patient is unwilling or unable to learn, any education given will not be received
- Intervention (2): Help the client locate appropriate follow up resources for continuing information and support (Ackley 10th edition, p. 505). Rationale: If the clients have continuing questions following discharge, they will have a source from which to receive accurate information
- Intervention (3): Use a family-centered approach (Ackley 10th edition, p. 505). Rationale: Family can also learn about what behavors are normal and what is abnormal and can help the mother in reinforcing what was learned
- Intervention (4): Use visual aids in teachings (Ackley 10th edition, p. 505). Rationale: Will allow client to understand what they are learning in a visual manner, possibly increasing their recollection and understanding
- Intervention (5): Repeat and reinforce information during several brief sessions (Ackley 10th edition, p. 506). Rationale: The patient may be overwhelmed with so much information about caring for her newborn and her new role, and thus repeating and reinforcing information can increase understanding and promote greater comfort in caring for the baby
- Evaluation: Goal met. The patient and her family demonstrated an understanding of the teaching and expressed more comfort with the newborn's behavior after the teaching
- Intervention (5): Repeat and reinforce information during several brief sessions (Ackley 10th edition, p. 506). Rationale: The patient may be overwhelmed with so much information about caring for her newborn and her new role, and thus repeating and reinforcing information can increase understanding and promote greater comfort in caring for the baby
- Intervention (4): Use visual aids in teachings (Ackley 10th edition, p. 505). Rationale: Will allow client to understand what they are learning in a visual manner, possibly increasing their recollection and understanding
- Intervention (3): Use a family-centered approach (Ackley 10th edition, p. 505). Rationale: Family can also learn about what behavors are normal and what is abnormal and can help the mother in reinforcing what was learned
- Intervention (2): Help the client locate appropriate follow up resources for continuing information and support (Ackley 10th edition, p. 505). Rationale: If the clients have continuing questions following discharge, they will have a source from which to receive accurate information
- Intervention (1): Consider the client's abilities and readiness to learn (Ackley 10th edition, p. 504). Rationale: If the patient is unwilling or unable to learn, any education given will not be received
- Goal: patient verbally expressed relief of worry and demonstrates learning of teaching by the end of the shift
- AEB expression of worry regarding proper baby feeding and voiding habots
- r/t life role change
- Family @ bedside for support
NKDA
C/S wound on lower abd open to air + binder and steri strips
Delivered to baby girl at 0544
EBL 810mL
Breastfeeding
Hx: Epilepsy
Lochia rubra scant
- S/p Foley cath. Voided 850mL (hematouria present due to lochia)
VS: 120/70, HR 80, RR 18, O2 95%, 98.9 F, 2/10 pain
- Pain well controlled via meds
Labs: Hgb 10.2 (L), Hct 29.8 (L), RBC 3.33 (L), WBC 17.7 (H)
- Deficient fluid volume
- r/t c/s delivery
- AEB low Hgb and Hct, large voids,
- Goal: The patient will not exhibit signs of FVD and will maintain a SBP of 100+ and nave no episodes of orthostatic hypotension
- Intervention (1): Monitor fluid intake and output (Ackley 10th edition, p. 367). Rationale: Will identify progressive resolution of deficient status
- Intervention (2): Provide oral replacement therapy as ordered (Ackley 10th edition, p. 367). Rationale: Will encourage natural fluid replacement with decreased risk of IV infection or volume excess
- Intervention (3): Check orthostatic hypotension (Ackley 10th edition, p. 367). Rationale: Will indicate if patient is compensating well to the blood loss and if additional precautions are indicated regarding fall risk
- Intervention (4): Teach the client about appropriate diet an fluid intake to replace fluid loss (Ackley 10th edition, p. 369). Rationale: Will include the patient's choices and active participation in plan of care
- Intervention (5): Monitor BP, pulse, and RR at least every 4 hours (Ackley 10th edition, p. 366). Rationale: Will alert of any changes or compensation regarding fluid status
- Evaluation: Goal was met. The patient had significant intake of fluids and did not present with episodes of hypotension/orthostatic hypotension
- Intervention (5): Monitor BP, pulse, and RR at least every 4 hours (Ackley 10th edition, p. 366). Rationale: Will alert of any changes or compensation regarding fluid status
- Intervention (4): Teach the client about appropriate diet an fluid intake to replace fluid loss (Ackley 10th edition, p. 369). Rationale: Will include the patient's choices and active participation in plan of care
- Intervention (3): Check orthostatic hypotension (Ackley 10th edition, p. 367). Rationale: Will indicate if patient is compensating well to the blood loss and if additional precautions are indicated regarding fall risk
- Intervention (2): Provide oral replacement therapy as ordered (Ackley 10th edition, p. 367). Rationale: Will encourage natural fluid replacement with decreased risk of IV infection or volume excess
- Intervention (1): Monitor fluid intake and output (Ackley 10th edition, p. 367). Rationale: Will identify progressive resolution of deficient status
- Goal: The patient will not exhibit signs of FVD and will maintain a SBP of 100+ and nave no episodes of orthostatic hypotension
- AEB low Hgb and Hct, large voids,
- r/t c/s delivery
- Deficient fluid volume
Meds: Docusate sodium, Ferrous Sulfate, Prenatal Vitamin w/ Folic acid, Simethicone, Ibuprofen, Lactated Ringer's
- LR D/C at 0945 following void, diet progression
L hand 20G IV
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- Mind Map on Postpartum Patient, created by Jonathan Aparicio on 22/02/2018.
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- Jonathan Aparicio
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