THE CLIENT AT 4 HOURS TO 2 DAYS POSTPARTUM

THE CLIENT AT 4 HOURS TO 2 DAYS POSTPARTUM -...

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THE CLIENT AT 4 HOURS TO 2 DAYS POSTPARTUM CLIENT ASSESSMENT DATA BASE Progressive continuation of data base for stage IV. Activity/Rest Extreme fatigue and decreased energy level may be noted. Insomnia may be noted. Circulation Diaphoretic episodes occur more often during night. Ego Integrity Irritability, tearful/crying (“postpartum blues” often noted about day 3 following delivery) Elimination Diuresis between day 2 and 5. Constipation may occur. Food/Fluid Loss of appetite may be reported at about day 3. Pain/Discomfort Perineal soreness from stretching, and sutures if episiotomy performed/laceration occurred Uterine contractions strong and regular in first 24-hr period, diminishing daily in frequency and intensity Safety Headache may be reported (subarachnoid/spinal block). Sexuality Uterus between one finger breadth above to two finger breadths below umbilicus at 12 hr following delivery,  descending approximately one finger breadth daily thereafter Lochia rubra continues for 2–3 days, progressing to lochia serosa with flow dependent on position (e.g., recumbent  versus up and ambulating) and activity (e.g., breastfeeding or exercise). Breasts: Production of colostrum first 48 hr progressing to mature milk, usually by day 3; may be earlier, depending on  when breastfeeding is begun and how frequently mother nurses infant NURSING PRIORITIES 1. Promote comfort and general well-being. 2. Prevent complications. 3. Support family bonding. 4. Provide information and anticipatory guidance. DISCHARGE GOALS 1. Physiological/psychological needs being met 2. Complications prevented/resolving 3. Family bonding initiated 4. Postpartal needs understood
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NURSING DIAGNOSIS: PAIN [acute]/[DISCOMFORT] May Be Related To: Mechanical trauma, tissue edema/engorgement or distension,  hormonal effects Possibly Evidenced By: Reports of cramping (afterpains), headache, perineal discomfort, and  breast tenderness; guarding/distraction behaviors, facial mask of pain DESIRED OUTCOMES/EVALUATION  Identify and use appropriate interventions to  CRITERIA—CLIENT WILL: manage discomfort. Verbalize lessening of levels of discomfort. ACTIONS/INTERVENTIONS RATIONALE Independent Determine presence, location, and nature of  Identifies specific needs and appropriate  discomfort. Review labor and delivery record. interventions. Inspect perineum and episiotomy repair. Note  May reflect excess trauma to perineal tissue  edema, ecchymosis, localized tenderness,  and/or developing complications requiring  purulent exudate, or loss of approximation of  further evaluation/intervention. suture line. (Refer to ND: Infection, risk for.)
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THE CLIENT AT 4 HOURS TO 2 DAYS POSTPARTUM -...

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