Post Partum Assessment

Ryan Davis2/28/12 Seton Hall University College of Nursing NUTC 3914 Maternal Newborn Nursing Post Partum Assessment Mother’s initials: CC • Age of Mother : 36 Allergies • Medications: NKDA • Food: None • Environmental: None Gravida Para: 1, Gravinda 4 • Term : 2 • Pre-term : 0 • Abortion : 2 • Living : 2 Age of siblings : 4 Type of delivery • Normal Spontaneous Vaginal delivery (NSVD) or caesarean-section delivery • Length of labor (if applicable) • Partner or Spouse available : yes, he is by the mother’s bedside. Anesthesia (local, spinal, epidural, and/or general) : Elective C- Section • Was this a high-risk pregnancy of labor and deliver? (If yes, explain) : Yes, Mother has Thyroid disease and HPV.

Baby • Sex : Female • Weight : 6lbs 4onces • Apgar (1 and 5 minute) : 9-9 • Breast or Bottle-feeding : Bottle Activity of mother • Mother is sitting in the chair and feed baby while gazing at her indearly. Diet of mother • Regular and whole General postpartum assessment findingsMom appears to be healthy, comfortable, in no pain, has no complaints or complications. Vitals Signs • Temperature : 97. 4 Tympanic Temperature • Pulse : 84, Regular and Full • Respirations : 22 BPM while talking • Blood pressure : 112/ 79 NEURO • Alert and oriented : Mom is AOx4, Person, Place, Time, Situation • Lethargic • Restless • PERRLA : Pupils are Equal Round and Reactive to Light with Accommodation • Behavior Psychosocial • Maternal newborn attachment (describe): Feeding and holding baby.

Smiling and involving family. Readiness and receptive behavior for postpartum teaching (describe): Watched video on Post-partum depression. • Signs of being anxious, depressed, uncooperative, etc. (if present, describe): None present • Partner or spouse available and/or supportive (if present, describe): Yes, partner is by the mother’s side and actively engaging baby. Skin • Color (pink, brown, pale, cyanotic, or flushed): Pink • Temperature (warm, hot, or cool): Warm • Humidity (dry, moist, clammy, or diaphoretic): Dry Respiratory Breath sounds (anterior and posterior): Bilaterally Clear to Auscultation. No stridor, wheezing, rales, ronchi, gurgling or snoring present.

Heart Sounds • S1 and S2: Present • Murmur: None present Breasts • Wearing bra: Yes, Supportive • Soft, filling, firm, engorged, redness, or area of tenderness or discomfort (if present, describe): Breast or filling with no tenderness present. • Nipples (intact, reddened, sore, cracked, inverted, and/or using breast shields): No cracking, redness, edema, pain, or outwardly signs present. Nipples are intact and healthy appearing. Comfort measures used for breastfeeding or non-breastfeeding mother (bra, ice, no stimulation, analgesics, cabbage leaves, tea bags, lanolin cream): None Newborn feeding (Document mother’s answers in quotes) 1. It is important to feed the baby on demand.

Do you know what this means? : Mother understands that it is important to feed her baby when she gets hungry and at regular intervals. 2. Describe how and when to burp the baby. : The baby should be burped at every half once.

3. How do you know the baby is getting enough formula or breast milk? Because the baby detaches from the nipple and stops sucking. 4. How do you use a breast pump (if applicable)? : The patient had a lactation nurse explain the procedure to her. 5.

What does a lactation diet include? Eat a well-balanced diet for your health, Don't count calories, Aim for slow and steady weight loss, Include a variety of healthy foods, Choose good fats, Take extra steps to avoid contaminants, Eat fish - but be picky, Go easy on the alcohol, Drink plenty of water and limit caffeine, Consider the flavors of what you eat and drink, Keep taking your vitamins . Would you like to see a lactation nurse? Yes Abdomen • Symmetric or asymmetric: Soft, dough and symmetrical. • Distended: Yes, due to recent delivery of baby. • Bowel sounds present in all four quadrants: Yes, normal active bowel sounds in all 4 quadrants. • Flatus present: None • Bowel movement since delivery: none, on stool softeners Fundal Height (circle one) • FF@U • FF@ U-1 • FF@U_2 • FF@U_3 • FF@U+1 Fundal Location (circle one) • Midline • Right of umbilicus • Left of umbilicus Fundal consistency (circle one) Firm • Boggy • Firm after massage Lochia • Type (rubra, serosa, or alba) • Amount (scant, small, moderate, or heavy) • Presence of clots (if yes, describe size) Bladder • Foley catheter: None present • Has mother voided since delivery? : Yes, I did not observe the amount and color • Has mother voided prior to postpartum assessment? : Yes, I did not observe the amount and color • Is bladder non distended? : Yes Perineum • Intact: Yes, fully intact.

Was not a vaginal birth. No REDDA is present. Any ecchymosis, hematoma, or edema: No, none present • Episiotomy: (right mediolateral, left mediolateral, or midline episiotomy) : None performed • Laceration (first, 2nd, 3rd, or 4th degree) : None present • What comfort measures are being used? (ice, tucks, cream, spray, sitz bath, pain medication)? : Motrin 800mg and Percocet 5mg C-section • Dressing dry and intact: Not present. Dressing removed by surgeon. • Type of incision (classical or vertical): Lower Uterine Transverse • Staples or stitches and are they intact: Staples used.

Approximated well with no REDDA present. Bowel movement since delivery: None present Legs • Non pitted or pitted edema (0, +1, +2, +3, +4) (bi-lateral or unilateral): no edema present • Pain (if yes, include full pain assessment) : No pain or tenderness present • Homan’s sign (positive or negative) (bi-lateral or unilateral) : Homan’s sign is negative bilaterally Intravenous • Type (IV or hep loc): None present • Site and appearance : No IV site present • IV Solution: No IV Solution present • Rate: cc/hr : No IV drip rate present Pertinent Lab Data: Mother • Blood type and Rh factor : AB - Negative • Blood glucose (if applicable): Did not obtain.Mother is not a diabetic • HgB/HCT : 14/41 • Additional lab tests: Group B Strep Positive Newborn • Blood type and Rh factor: A-Positive • Blood glucose (if applicable) • HgB/HCT • Additional lab tests PP Teaching provided (describe) I informed the patient to use a pillow to brace her incision when she sits up or when she sneezes and coughs. Newborn teaching provided (describe) I informed the patient that the baby should be burped every half an ounce and I told her to check the patency of the nipple of the bottle so ensure that the baby is getting enough formula without working so hard.