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NA, 32
Diagnosis: Spontaneous Vaginal Delivery
G3P2A1L2 (Assessment (H:…
NA, 32
Diagnosis: Spontaneous Vaginal Delivery
G3P2A1L2
Assessment
H: Thrombus
No signs of DVT, calves free of redness, pain, & swelling
No dyspnea
E: Emotions
Patient has not slept since delivery
States no feelings of sadness, depression, or any other negative signs
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D: Discomfort
Patient is taking 800 mg Motrin q8h for pain
Reports no discomfort and that pain is under control
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BB: Bowel/bladder
Urinating, no issues
No BM as of 4.8
Passing flatus
Taking stool softeners
U: Uterus
Firm, midlife, 1 finger below umbilicus
B: Breastfeeding
No tenderness or redness
Colostrum present, no milk
Troubles latching, getting better at end of shift
Last feed @ 1030 for 50 mins
Nursing Concepts Altered
Patient had no pain medication during labor #
No lacs or tears causing excessive pain #
No severe swelling noted #
Taking Motrin q8h to control pain #
Patient is voiding regularly #
Has not passes a BM since birth # #
Patient is taking stool softeners and increasing fluid intake # #
Post-vaginal birth of second child #
No pain medication or epidural during delivery #
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Late term delivery: 41 w, 2d
Patient is not sleeping due to husband snoring #
Patient has been resting comfortably in room but appears tired #
Lab Results
HBsAg: Negative
Expected result; no action/treatment needed
Normal value: Negative
(Murray & McKinney, 2014, p. 109-110)
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Rubella: Immune
Expected result; no action/treatment needed
Normal values: Immune
(Murray & McKinney, 2014, p. 109-110)
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Medications
Colace 100mg 1 capsule/daily # #
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Patient Outcomes
Patient will demonstrate how to properly latch infant yo breast prior to discharge. # #
Patient will understand signs and symptoms of a thrombus by the end of shift as evidenced by teach back. # #
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Patient will maintain stable condition postpartum as evidenced by stable vitals and no adverse events during shift. #
Pathophysiology
The uterus contracts involuntarily & intermittently to help move the fetus from the uterus through the birth canal & vagina (Murray & McKinney, 2014, p. 214). #
The cervix must be dilated to 10 cm and effaced 100% for labor to be true & birth to be successful #
Risk Factors
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Previous spontaneous Abortion # #