MEDICATIONS

Acetaminophen 325mg every 6 hours PRN
Oral, for pain
Azithromycin tabs daily, oral, infection at the incision site
Cefdinir 300mg every 12 hours, oral, infection at the incision site
Docusate/Sennosides 2 tabs 2x daily, oral, stool softener
Lanolin PRN, topical, breast maintenance

LABS

CBC-WBC 14.4, increased due to infection
Hemoglobin 8.0 & Hematocrit 22% due to blood loss

Vitals
B/P 110/59
Heart rate 99 bpm
respirations 20
Temp 99.9
PO 97%
Pain level 6/10

NURSING INTERVENTIONS

Dispense prescribed pain meds as needed
Provide comfort measures by repositioning patient
Provided a quite environment
Teach patient relaxation techniques
Encourage diversional activity such as watching television

Patient will verbalize pain at 1 or 2 on pain scale prior to discharge

Patient will verbalize 4 out of 10 on the pain sale 20 minutes after pain pain delivered

NURSING INTERVENTIONS

Assess the structure of the beast and nipples
Assess the mothers knowledge of lactation and breastfeeding
Assess psychosocial factors that can contribute to ineffective breastfeeding
Assess presence of support, such as, family,/partner

Infant shows an adequate intaking within 24 hours

NURSING INTERVENTIONS

Encourage patient to take in 2000-3000 ml of fluid a day
Assist patient in taking 20 g of dietary fiber
Dispense stool softeners are prescribed
Encourage warm sitz baths

Patient maintains a "normal" stools prior to discharge.

NURSING INTERVENTIONS

Monitor vital signs
Monitor intake output
Assess for bleeding
Administer medication as ordered

Pt will have blood pressure and heart rate WNL prior to discharge

Patient will have a balanced 24-hour intake and outpout