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Patient: N.G.P. 36 y/o female 08/31/2020 G4P3003 41w1d Primary…

- - - - Encourage pt. to use relaxation techniques to reduce pain (Ackley, 2017, p. 225).
      - Eval: Pt. tries laying on her left side to relieve pressure. Pt. tries guided imagery to take her mind off the pain and control her breathing.
      - Encourage mobilization or change of position to decrease pain (Ackley, 2017, p.225).
      - Assess pt.'s current comfort level and ask if anything relieves it (Ackley, 2017, p. 225).
- - - - pain level: 0/10
      - watch for respiratory depression and put patient on oxygen to ensure baby has enough oxygen for labor
  - - - Evaluate fluid stasis and assess for dehydration (Ackley, 2017, p. 388).
      - Encourage pt. to express feelings and behaviors that cause fatigue (Ackley, 2017, p. 388).
      - assess severity, frequency, and what activities or symptoms that increases pt.'s fatigue (Akley, 2017, p. 388).
      - Eval: Pt. states she has not slept since her AROM was at 0255 and rates her fatigue as 6/10.
- - - - contractions 2-3 min apart
      - monitor for water intoxication, electrolyte imbalances, and hypertension
- - - - Check the episiotomy/laceration site for signs of edema, erythema, separation of wound edges, and purulent drainage (Ackley, 2017, p. 343).
      - Teach and demonstrate proper hand washing and peri-care techniques (Ackley, 2017, p. 343).
      - Observe for signs of fever, chills, pelvic pain, or uterine tenderness (ackley, 2017, p.343).
      - Eval: pt. teaches back proper hand washing and peri-care techniques.