THE CLIENT AT 24 TO 48 HOURS FOLLOWING EARLY DISCHARGE

THE CLIENT AT 24 TO 48 HOURS FOLLOWING EARLY DISCHARGE -...

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THE CLIENT AT 24 TO 48 HOURS FOLLOWING EARLY  DISCHARGE This plan of care focuses on the client who is discharged within 30 hr of delivery. It is to be used in conjunction  with CP: The Client at 4 Hours to 2 Days Postpartum. CLIENT ASSESSMENT DATA BASE Circulation BP remains at same level as pregnant readings (slightly below baseline). Pulse between 60 and 90 bpm. Superficial varicosities may be visible in lower extremities. Ego Integrity May feel isolated, anxious, depressed, or fatigued, even though early discharge had been desired by client May report stressors (e.g., employment, financial, living situation), concerns about personal abilities and assumption of  mothering role Elimination Voiding 100 ml or greater in amount, without suprapubic tenderness or retention. Probably has not experienced a return of normal bowel habits. Hemorrhoids varying in size and number may be present. Abdominal musculature may be weak and of “bread dough” consistency. Food/Fluid Weight reduced by 10–12 lb following delivery. Physiological edema may still be present. Pain/Discomfort Discomforts associated with episiotomy, perineal trauma, hemorrhoids, or afterpains. Breast tenderness/engorgement may occur between days 3–5 postpartum. Uterine contractions diminishing daily in frequency and intensity. Safety Lochia rubra moderate in amount with fleshy odor; may increase during breastfeeding. Striae may be present on abdomen, breasts, and thighs. Perineum or site of episiotomy repair may be edematous with good approximation of wound edges. Sexuality Breasts soft, nontender, and free of masses Nipples soft and free of fissures or lesions Uterus firm, midline, and located at or just below the umbilicus (uterus is larger in multipara or in client with  overdistension) Social Interactions May now report lack of/or inadequate support systems; concerns regarding roles of individual family members, role  mastery, or disequilibrium (especially in blended family)
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DIAGNOSTIC STUDIES Routine assessment may include CBC or Hb/Hct and UA, and culture and sensitivity, as indicated by physical findings. NURSING PRIORITIES 1. Determine postpartum status of client. 2. Promote optimal physical and emotional well-being. 3. Facilitate client’s/couple’s positive adaptation to parenting roles, family growth, and autonomy. NURSING DIAGNOSIS: PAIN [acute]/[DISCOMFORT] May Be Related To: Mechanical trauma, tissue edema/engorgement or distension,  hormonal effects, excessive fatigue Possibly Evidenced By: Reports of cramping (afterpains) and perineal discomfort,  guarding/distraction behaviors DESIRED OUTCOMES/EVALUATION  Identify sources of discomfort.
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This note was uploaded on 02/01/2011 for the course PNR 182 taught by Professor Toole during the Spring '10 term at Orangeburg-Calhoun Technical College.

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THE CLIENT AT 24 TO 48 HOURS FOLLOWING EARLY DISCHARGE -...

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