University:
Lincoln University
Course:
NUR301 | Fundamental of Nursing
Academic year:

2024
Views:

204

Pages:

2
Author:

Bobby E.

Stage 4 Assessment - Activity Client appears energized or exhausted - Circulation Pulse is usually slow to (50-70x/minute) BP varies, may be lower in response to analgesia/anaesthesia, or increase in response to administration of oxytisin or HKK, edema, blood loss during labor 400-500 ml for vaginal birth 600-800 ml for Caesarean birth - Ego integrity Disappointment, fear about the baby's condition, happiness - Elimination Hemorrhoids, bladder palpable above the symphysis pubis - Food/liquid Complaining of thirst, hunger or nausea -Neurosensory Lower extremity sensation and movement are decreased in the presence of spinal anesthesia - Pain/discomfort Reporting pain, for example due to tissue trauma or episiotomy repair, bladder fullness, feeling cold or muscle tremors - Security Increased body temperature - Sexuality The fundus is firm, contracted, located at the level of the umbilicus, the perineum is free from redness, edema, ecchymosis or discharge. Striae may be present on the abdomen, thighs and breasts. Nursing Diagnosis and Nursing Plan 1) High risk of fluid volume deficiency related to fatigue/myometric tension from homeostatic mechanisms eg: HKK effectIntervention: a)Place the client in the recumbent position b)Examine things that aggravate intraportal events c)Pay attention to the type of labor and anesthesia, blood loss during labor d)Assess BP and pulse every 15 minutes e)Gently massage the fundus if it is soft f)Assess the amount, color and nature of locheal flow 2) Acute pain related to hormonal effects, mechanical trauma/tissue edema, physical and psychological fatigue, anxiety Intervention: a)Assess the nature and degree of discomfort b)Provide appropriate information about care during the postpartum period c)Inspect episiotomy or wound repair d)Take comfort measures e)Encourage the use of relaxation techniques f)Give analgesics as needed