Nursing Postpartum Assessment Narrative Format PDF

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Postpartum Nursing Assessment in Narrative Format...

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Anonymous Post Partum Narrative Assessment A patient was assessed with the initials of S.V. on the day of March 28 th, 2017. S.V. is a 31-yearold Gravida 2 Para 2 German-American Caucasian female who is 1 day post partum in the Maternity Unit at Paoli Hospital, in Paoli, Pennsylvania. The patients TPAL is 2-0-0-2. Her delivery was a caesarian section who delivered on March 27th, 2017 at 0921. The patient required an episiotomy with a midline second degree laceration. Labor took approximately 3 hours, and the patient’s pain was eased by an epidural. The estimated blood loss was approximately 1 liter, which was extracted and measured by nurses in the operating room. The patient’s blood type was O, and a rhesus status of +, making the blood type O+. This result indicated that the patient did not require a Rhogam immunization. An antibody screen was not given, for reasons unknown to the student nurse. The prenatal Complete Blood Count was 12.1 g/dL. On the rubella immunization titer, the patient was found to be immune. On analysis of the Rapid plasma reagin, the patient was found to be negative. This means that syphilis was not found in the blood. The HIV screening reported negative. Similarly, the Hepatitis B result was negative or “non-reactive.” Upon testing for gestation diabetes, the patients results were for the 1-hour GTT: 132mg/dll. This is a good result, and did not require further testing. Lastly, the Group B streptococcus titer has a resulted in a negative, which means S.V was uncolonized by group b streptococcus. Fetal tests were arranged accordingly. The test administered were: Ultrasound, Amniocentesis, and a nonstress test. The ultrasound was performed at 21 weeks to determine the health of the fetus. The amniocentesis was performed to determine potential chromosomal abnormalities. The nonstress test was performed to determine the baby’s movement, heartbeat, and contractions.

The patient has a family history of breast cancer in the maternal line, and diabetes mellitus type II in the paternal line. The patient’s last menstruation occurred on June 18th, 2016. The sexual history of the patient is negative for any kind of sexually transmitted infection. The patient’s pregnancy was uncomplicated. Pre-pregnancy weight was 120. Weight on admission was 151. Blood pressure remained stable throughout pregnancy, never getting hypertensive and increasing only slightly. The blood pressures were as followed: at first pre-natal visit 115/78, at 28 weeks gestation 128 / 84, and at Term: 130 / 88. Significant Assessment Data:

The patient was assessed using the BUBBLEDEP assessment formula. The patients breast tissue felt a little sore and soft when asked, and no other significant findings were observed. Upon palpation, the fundus was found to be firm at +1 position.The patient is voiding and urinating without issue. The next part of the assessment consisted of inquiring about GI status; the patient is eating, and appetite is growing. Lochia, upon assessment, was found to be a deep red, charted as rubra, with a moderate amount that was lessening over time. The perineum incision was found to be well approximated, red, non-edematous and healing. The patient was not at risk for Deep-Vein Thromosis, due to ambulating occasionally, and a lack of varicose veins on the leg. Upon physical assessment of vital signs: Heart Rate: 69bpm, Respiratory Rate of 15 breaths per minutes, Temperature of 97.3F, and a blood pressure of B.P.: 121/81. On assessment, the patient stated her pain was a 4/10. This was an indication to ask the nurse for Motrin to help alleviate pain. Sleep was assessed and no issues were detected with the patient receiving 8 hours of sleep each evening. Lastly, emotional health was assessed, and the patient reported happy and excitable moods. When asking about birth control, the patient reported using barrier methods such as condoms. The postpartum phase at the time of the assessment was the taking-in phase. When asked about mother-child interactions, the patient reported skin-skin, regular interval breastfeeding, and tummy-time or ‘kangaroo

care.’ DISCHARGE PLANNING The patient was eager to return home and to be a nurturing parent. The patient had only a single knowledge deficit regarding when to receive vaccines. A quick breakdown of the CDC vaccination schedule was provided, with a recommendation for a follow-up with the patient’s pediatrician to receive the immunizations at appropriate times. Finally, the patient was provided reinforcement education to regarding signs of postpartum blues and the differences from postpartum depression. Most importantly, the patient was educated when to contact healthcare provider due to postpartum depression. Lastly, patient and her significant other watched an education movie about shaken baby syndrome prior to discharge....