Care of the Childbearing Family Concept Map

Postpartum Nursing Care *Complete ‘physiologic changes’ section on p. 1 and ‘Textbook Profile’ section on p. 2 prior to your clinical experience* Client Age: 37 years old Psychosocial highlight any identified concerns Religious Affiliation: Catholic Pregnancy planned or unplanned? Planned Admission Date: 6/26/21 # children: Delivery Date: 6/26/21 Marital status: married 3 Ages: Erickson’s Developmental Stage: Educational level: Intimacy vs isolation Employment status: unemployed Pregnancy/Labor History EDB: 7/3/21 GTPAL: G7P4034 Date prenatal care started: first trimester Pre-pregnancy Weight: 88.9kg ; at the end of pregnancy weight103.9 kg Height: 5’ 2” BMI: 35.85 Weight gain appropriate during pregnancy? Yes weight gain was appropriate during pregnancy because the patient is obese and according to Center for Disease Control patient in this weight range normally can gain 25-42 pounds and our patient added 33 pounds to her weight. (Deputy, Sharma, & Kim, Living arrangements: with husband 2015) Tobacco/alcohol use (be specific): never Illicit drug use (be specific): never Medications during pregnancy: Vitamins and iron Preexisting conditions: T2DM Complications/infections/STI’s/illnesses during pregnancy: non Parenting class? no Induction (Y/N, if yes, type & time begun): 1st stage length: 9h 2nd stage length:1h 13 min. Medications during labor (& time administered): Ocytocin (2300), Cytotec (0730) Problems during labor: laceration second 1 Additional issues/areas of concern identified: Laboratory Results Lab Result Date (if known) 6/28/21 6/26/21 Hgb/Hct 12.2/36.9 Blood type & Rh+ Rh Syphilis negative 6/26/21 Rubella immune Group B Strep negative Hep B negative 6/26/21 Screening HIV status negative 4/13/21 Others Covid19 negative 6/26/21 Describe the physiologic changes that occur after delivery: involution Time 1-4 hours Changes Generalized physical fatigue due to delivery; pulse rate is elevated; blood pressure can be elevated due to pain or as sign of pre-eclampsia, or BP can be low because of post delivery hemorrhage or septic shock. Discharge from vagina as lochia with red color; the uterus and the Course/Section: ____________________________ Clinical Instructor:_____________________ degree , shoulder dystocia placental site contracts Type of delivery: vaginal with episiotomy rapidly to prevent further EBL __665____ mL blood loss. Episiotomy/tear (describe): second degree After 4 The temperature is slightly laceration bours elevated; respiratory rate begin to fall back to the prepregnancy level; weight loss of 5 to 6 kg due to expulsion of products of gestation and accompanying blood loss; discharge from vagina ( lochia) yellowish or pale brown color lasting 5 to 9 days comprised mainly of blood, mucus and leucocytes; then lochia become white color containing mucus and lasting 10 to 14 days. (Chauhan, Tadi, 2020) 2 Course/Section: ____________________________ Clinical Instructor:_____________________ Medications Drug Order Classification Purpose (this Side Effects Nursing client) Implications Docusate Stool Relieve Diarrhea, Monitor patient for Sodium(Colace) softener constipation abdominal signs of nausea, cramping, stomach vomiting stomach pain, throat pain before giving irritation, intestinal docusate sodium. obstruction, rash, low electrolyte level. Ibuprofen NSAID Pain killer Stomach pain, Monitor patient for (Motrin) feeling tired or signs of gastric and sleepy, GI duodenal ulcer. bleeding, tinnitus, Insulin Lispro antidiabetic Hyperglycemia Sweating, Monitor patient for dizziness, overdosage . cosign shakiness, hunger, with another nurse tachycardia, tingling in your hands feet lips or tongue, confusion, blurred vision. Insulin NPH antidiabetic hyperglycemia Sweating, Monitor for dizziness, overdosage. Cosign shakiness, hunger, with another nurse tachycardia, tingling in your hands feet lips or tongue, confusion, blurred vision. Physical and Emotional Assessment Vital Signs: BP 116/74, HR79, RR 16 T 37.2 Postpartum Textbook Profile Client Findings B – Breasts U – Uterus B– Bladder/Bowel P – Perineum 3 No swelling or redness, symmetric and soft to palpation Fundus at umbilicus midline Regularly urinating, no bladder swelling or GI distention, bowel movement 2-3 times a day No tear or irritation, no redness, no signs of Breast are small, globular with shortshafted nipples. Rank Order 1 Fundus firm at umbilicus 2 Urinating regularly/ abdomen soft no tender 3 Dressing after episiotomy with reparation 4 Course/Section: ____________________________ Clinical Instructor:_____________________ Postpartum Textbook Profile Client Findings Rank Order infection, proper healing if tear occurs. L – Lochia Minimal to moderate Similar to a period 6 flow L – Legs No signs of edema or No edema and warm in touch. 5 varicose veins, warm E – Emotions Stable and optimistic, Feeling well and well appearing 7 nurturing behavior and no signs of postpartum depression. System Neurological Additional Physical Assessment Client Findings No seizures, denies headaches, visual changes. Rank Order 1 Pulmonary No wheezing, denies dyspnea or cough. 2 Cardiovascular Denies chest pain or palpitations 3 Integumentary Intact , no signs of lesion, no bruises, warm and dry in touch. 6 Musculoskeleta l SensoryPerceptual Cultural beliefs & influences No flank tenderness, weakness, joints pain or swelling, nor muscle pain. No pain in general 5 4 Explain: Catholic and do not believe in abortion. Nursing Diagnosis #1: Risk for infection R/T labor and delivery AEB: laceration second degree/ episiotomy with reparation Short term goal: patient temperature will remain within normal range throughout the shift. Long term goal: patient will remain free from infection until discharge. Interventions (minimum of 4):  Monitor and record the patient’s temperature every 2 hours. Temperature elevation is early sign of infection.  Hand washing thoroughly, using proper technique, before and after providing care to prevent the spread of infection.  Use strict sterile technique when inserting I.V. lines to reduce the likelihood of nosocomial infection.  Maintain good patient hygiene. Clean the perineal area from front to back and keep the area dry to reduce the risk of infection. (Carrico, Garrett, Balcom, & Glowicz, 2018). 4 Course/Section: ____________________________ Clinical Instructor:_____________________ Nursing Diagnosis #2: Pain R/T postpartum physiologic changes AEB: perineal laceration and extension. Short term goal: patient will expresses comfort and relief from pain during the shift. Long term goal: patient will understand and carry out appropriate interventions for pain relief by discharge. Interventions (minimum of 4):  Assess patient’s pain symptoms to obtain information and plan appropriate nursing interventions.  As ordered, administer pain medications to provide pain relief.  Examine the episiotomy site for redness, edema, ecchymosis, drainage, and approximation to detect trauma to perineal tissues or developing complications.  As ordered, teach the patient how to use sprays, creams, and ointments for the perineal area. These products penetrate sensory nerve endings, providing a depressant effect on peripheral nerves, thereby reducing the response to sensory stimulation. (Petersen,2011). Nursing Diagnosis #3:impaired skin integrity. R/T episiotomy AEB: episiotomy with reparation. Short term goal: patient will perform skin care routine throughout the shift. Long term goal: Patient’s episiotomy incision will heal without infection. Interventions (minimum of 4):  Inspect incision during the shift using REEDA ( redness, edema, ecchymosis, discharge, and approximation) method. Document finding to detect signs and symptoms of possible infection.  Instruct and assist the patient with general hygiene, including hand-washing and toileting practices. Proper hand-washing is the most effective method of disease prevention. Bacteria from hands can easily contaminate other areas.  Teach the patient how to apply the maternity perineal pad. Tel her to apply a clean pad from front to back and to remove a soiled pad from back to front to decrease the risk of contaminating the vaginal area with stools.  Help the patient to assume a comfortable position to minimize the incidence of paininduced immobility. (Carrico, Garrett, Balcom, & Glowicz, 2018) Discharge Planning: List which interdisciplinary consults that would need to be initiated in order for the mother/infant to be discharged home. Along with community services consults that should be initiated.  Patient education on proper care of perineum and episiotomy incision  Patient education on monitoring her blood sugar level and on the use of insulin.  Patient education on signs and symptoms of hypoglycemia or hyperglycemia.  Follow up with Endocrinologist for her T2DM  Consult nutritionist since the patient is obese and diabetic. 5