THE CLIENT AT 1 WEEK FOLLOWING DISCHARGE

THE CLIENT AT 1 WEEK FOLLOWING DISCHARGE -...

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THE CLIENT AT 1 WEEK FOLLOWING DISCHARGE CLIENT ASSESSMENT DATA BASE Circulation Vital signs within normal limits Ego Integrity Emotional tone and responses may vary from one of delight to a sense of overwhelming disorganization or anxiety,  especially in first-time mother. Irritability, crying, “postpartum blues.” Elimination May report voiding difficulty or stress incontinence May report difficulty with bowel evacuation, with decreased frequency, hard-formed stool Pain/Discomfort May report continued discomfort associated with afterpains. Engorgement may be present in lactating client. Safety Episiotomy or cesarean incision free of edema, indurated areas, redness, and exudate; tissue edges approximated Sexuality Uterus nontender, palpable at symphysis pubis. Lochial flow scant and pinkish-brown in color (serosa) and of 4–10 days’ duration. Breasts in lactating client increased in size with increased milk supply. Nipples free of redness, cracks, and fissures. Engorgement may be present in lactating client, subsiding in nonlactating client. DIAGNOSTIC STUDIES Urine:  Negative for albumin/glucose. Additional testing as indicated; e.g., UA, culture and sensitivity, Hb/Hct or CBC to include WBC count. NURSING PRIORITIES 1. Promote maternal/infant well-being. 2. Foster optimal adaptation to physical emotional changes. 3. Provide anticipatory guidance for optimal integration of new family member and adaptation to role changes. NURSING DIAGNOSIS: FATIGUE, risk for Risk Factors May Include: Physical and emotional demands of infant and other family members,  psychological stressors, continued discomfort Possibly Evidenced By: [Not applicable; presence of signs/symptoms establishes an  actual  diagnosis] DESIRED OUTCOMES/EVALUATION  Identify basis of fatigue and individual areas of  CRITERIA—CLIENT WILL: control. Report improved sense of energy.
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ACTIONS/INTERVENTIONS RATIONALE Independent Discuss signs of excess physical and  Lack of energy, deep circles under the eyes, and  emotional fatigue. statements suggesting extreme fatigue indicate  inadequate sleep and rest. Self-monitoring and  awareness of developing problem allow for timely  intervention. Review intrapartal and early postpartal events. Cumulative sleep loss must be overcome as soon as  possible to facilitate psychological and physiological  recuperation. Determine infant’s sleep-wake cycles. Suggest  Helps infant to maintain progressively longer  ongoing efforts to modify the infant’s behaviors  wakeful periods during the day and to sleep  to promote more wakeful periods during the  longer stretches at night. Note: Approximately  daytime and recommend that mother naps when  5 wk are needed to regulate the infant’s cycle.
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THE CLIENT AT 1 WEEK FOLLOWING DISCHARGE -...

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