Postpartum Recovery Patient

Postpartum Recovery Patient

1. 28yo F pt G4P4 s/p C-section delivery at 39w0d

   • VS: BP 96/54, HR 86, RR 18, Temp 98.7 F, Pain 0/10
   • Pt had spinal block for procedure that remained effective at time of assessment and thus reports no pain
     • No sensation or ROM on bilateral lower extremities distal to hip
       • Braden Scale score 13
         • Bed rest order
       • SCDs on LE
   • NKDA
   • Meds: Lactated Ringer's at 125mL/Hr, Ancef, Bicitra
     • Pitocin also prescribed but witheld due to scant discharge and contracted uterus
   • EBL 445mL
     • LR @ 125mL/Hr

2. Wound clean and dry with dressing

3. Hx: Small bowel obstruction, obesity

   • BMI 36

4. Obs Hx: 2 previous C-sections

   • Risk for role strain
     • r/t major life change, addition of third child to family unit
       • Goal: The patient will demonstrate proper adaptation to her new role as evident by her interactions with the newborn prior to discharge
         • Intervention (1): Assist new parents to adjust to changes in workload associated with childbirth (Ackley 10th edition, p. 665). Rationale: will help the parents slowly transition into their roles with guidance
           • Intervention (2): Allow the client to express feeling regarding the role change and refer for support as needed (Ackley 10th edition, p.665). Rationale: validates their worries and helps identify the causes of stress and assesses the proper guidance that is needed
             • Intervention (3): Reinforce the client's strengths and internalized values (Ackley 10th edition, p.665). Rationale: helps the client identify their abilities and potential
               • Intervention (3): Encourage family to use support groups or other services to assist with the role change (Ackley 10th edition, p. 667). Rationale: Can help facilitate the change by connecting the client with others facing the same challenges
                 • Intervention (5): Provide educational materials to family members on client behavior management plus caregiver stress coping management (Ackley 10th edition, p. 667). Rationale: Can help manage the stress caused by the new roles through coping mechanisms and family support
                   • Evaluation: Goal evaluation not possible due to timeframe

5. Surgical Hx: Lumbar spine correction following MVA in 1998

6. Uterus hard and contracted

   • Lochia rubra scant

7. Breastfeeding

   • Ineffective breastfeeding
     • r/tknowledge deficit
       • AEB ineffective infant latch-on
         • Goal: The patient will demonstrate proper breastfeeding form and complete a successful feeding by the end of the shift
           • Intervention (1): Use valid and reliable tools to measure breastfeeding performance and to predict early discontinuance of breastfeeding whenever possible/feasible (Ackley 10th edition, p.168). Rationale: Accurate assessment of breastfeeding ability and identification of cause
             • Intervention (2): Instruct the client on maternal breastfeeding behaviors/techniques (Ackley 10th edition, p.169). Rationale: increases the odds of proper latch on if mother is using proper technique
               • Intervention (3): Avoid supplemental feeding (Ackley 10th edition, p.168). Rationale: According to Ackley, supplements contribute to a correlation in the decrease of exclusive breastfeeding
                 • Intervention (4): Provide information regarding infant cues and behaviors related to breastfeeding and appropriate maternal response (Ackley 10th edition, p.169). Rationale: promotes feedback to mother regarding successful breastfeed and encourages maternal improvement
                   • Intervention (5): Provide education to father as needed (Ackley 10th edition, p.169). Rationale: Mother is not in the optimal stage for learning following delivery and father can help encourage mother to improve successful breastfeed and mother-baby bond
                     • Evaluation: Goal met, as the patient showed readiness to learn, was able to demonstrate proper breastfeeding form, and completed a successful feeding of the newborn

8. Pt also uderwent tubal ligation

9. Minimal, severely decreased bowel sounds