Nursing Case Analysis Essay
1. Diagnosis: Risk for injury r/t bleeding from uterine atony, retained placental fragments, lacerations, or hematoma.
Short term goal: Patient will not experience any excessive bleeding & Patient will verbalize an understanding about warning signs of excessive bleeding
Long term goal: Patient’s bleeding will be lighter in color and she will regain her prepregnant state without complications to hemorrhage.
1. Assess and teach pt to palpate uterus for height and firmness and location
- Following birth the fundus has to be firm and should decrease one finger breath a day or more if breastfeeding from the umbilicus. A fundus that is hard tells you the uterus is contracting. If the fundus is above the umbilicus, boggy, blood may be collecting in the …show more content…
uterus and will stop effective contractions leading to hemorrhage.
Evaluation: My patient’s uterus was firm and 1 finger breath below the umbilicus. This is appropriate for her 1st postpartum day. I taught my patient how to feel her own uterus and the early signs of bleeding. She was able to repeat back the information I provided her. My patient is at low risk for injury.
2. Assess patient’s bladder.
- Incomplete emptying of the bladder can lead to bladder distention, which can interfere with the ability of the uterus to contract. If the uterus does not contract properly this can increase the risk of bleeding. A full bladder would also push the fundus to the right.
Evaluation: My patient was up and about voiding twice during my care. She told me that she was not having any trouble or pain urinating. Her urine was clear with tiny drops of blood. Her bladder was not distended.
3. Assess and teach patient to check amount, consistency, and color of lochia.
- The type, amount, and consistency of lochia determine the stage of healing of the placenta site, and a progressive change from bright red at birth to dark red to pink and then to white or clear drainage should occur. Saturation of a pad within 15 to 30 minutes may indicate hemorrhage.
Evaluation: I assessed my patient’s lochia by checking her peripad. Lochia was a moderate amount and dark rubra. She had changed her pad twice during my care. I taught the patient about her lochia and explained to her that increased amount on lochia on the peripads should be reported as it may be an indication of hemorrhaging. Patient stated that she would monitor her peripads daily.
4. Assess vital signs along with labs (H+H).
- A decrease in blood pressure and increase in heart rate may be a sign of hypovolemic shock (bleeding). Her labs will show a decrease in hemoglobin and hematocrit if there is bleeding present. If labs were to be drawn up stat, it would take less than an hour to get the results back. I would also assess her O2 saturation and check her ABG values. This would be able to also show me if she is bleeding.
Evaluation: My patient’s vital signs were within normal limits. Her blood pressure was 123/67, HR 77, Temp 98.1, R 20, and pulse ox 98%. Her H+H were 11.4L and 33.8L. This was slightly low but not a big issue because she is pp day 1 and the normal H+H is 11.5-15.5 and 34.5-45.0.
5. Encourage breast feed.
- This will stimulate the release of oxytocin from the pituitary gland. Oxytocin promotes constriction of the blood vessels and the uterus, thus preventing postpartum hemorrhage promoting involution.
Evaluation: Pt was able to breast feed her son for 20 minutes aiding the release of oxytocin. She did not complain of any pain at this time after breastfeeding.
6. Teach patient to eat foods rich in protein, iron and vitamin C.
- Protein is essential for tissue healing, iron is good for RBC restoration which helps to prevent anemia and vitamin c helps in iron absorption and also aid in tissue healing from the placental site.
Evaluation: Pt ate 100% of her breakfast and lunch. She is 18 years old and has a good appetite being at this age. She verbalizes understanding of how important iron is in her diet and about a good nutrition. She stated that she is very conscious about her nutritional intake and that she would continue to do so.
SUMMARY: GOAL WAS MET AS PATIENT VERBALIZES UNDERSTANDING ABOUT WARNING SIGNS OF EXCESSIVE BLEEDING & THERE WAS NO EVIDENCE OF BLEEDING.
2. Risk for infection (uterine, perineal, incisional, breast, urinary) r/t to childbirth.
Short term goal: Patient will not exhibit any sign of infection as evidence by a temperature < 100 while in my care.
Long term goal: By the end of postpartum period the patient will be free of infection.
1. Assess patient’s perineum for signs of infection using REEDA.
- My patient had a midline episiotomy done therefore any break in the skin and mucus membranes are portals of entry for infectious organisms. Infections cause inflammation characterized by pain, swelling, redness, and heat.
Evaluation: Patient’s perineum did not show any signs of inflammation. It was pink, well approximated, healing nicely with no drainage. Patient did not complain of any pain at this time.
2. Assess patient for generalized signs and symptoms of an infection. (pallor, fatigue, malaise, anorexia, and chills) and teach patient to report any of these signs.
- Prompt detection of an infection is essential as it helps to minimize complications. Early signs will detect immediate treatment.
Evaluation: I informed my patient about the signs and symptoms to be aware of such as fatigue and the chills. Pt was able to understand teaching by repeating back the information. Pt had no generalized signs and symptoms of an infection.
3. Promote perineal care.
- To prevent infection the patient should be informed to cleanse the perineal area daily with warm water and soap. The perineum should also be cleansed after every voiding and bowels using a squeeze bottle filled with warm water. The perineal area should be wiped from front to back to avoid contamination from the anal area.
Evaluation: My patient cleansed her perineal area after voiding twice. She had understood the correct way of keeping her area clean. She also put on a new clean peri pad after being cleaned. My patient was informed about the sitz bath and said that she would try it at home if any pain should occur. At the moment she did not have any pains.
4. Teach patient to change perineal pads frequently.
- Changing perineal pads often will decrease the chance of infection by decreasing the time lochia will be in contact with the perineal area. Lochia is a good medium for bacterial growth and clean pads decrease the risk of infection.
Evaluation: My patient had changed her pad every time she had voided and when they began to feel wet. She said she knew how to frequently change them b/c of the risk of infection. I would teach her to change her pad by removing it from front to back in order to prevent infections. This will help reduce concentrations of pathogens at the vaginal opening.
5. Monitor vital signs
- An elevated temperature, HR, BP, or RR may indicate and infection. Temperature greater than 100.4 F (38C) on two consecutive readings after the first 24hour post delivery may indicate sepsis, UTI, endometritis, mastitis, or other infections. Adaptations of mastitis include chills, headache, flulike muscle aches and malaise, and a warm, reddened painful area of the breast. Adaptations of metritis include bloody, foul smelling, and either scant or profuse discharge, temperature spikes jumping from 101 to 104, tachycardia, and chills.
Evaluation: Patient’s vital signs were within normal limits. Her blood pressure was 123/67, HR 77, Temp 98.1, R 20, and pulse ox 98%. There was no indication of infection noted.
SUMMARY: GOAL MET. PATIENT SHOWED NO SIGNS OR ADAPTATIONS OF AN INFECTION AS EVIDENCE BY BEING A-FEBRILE WHILE IN MY CARE.
3. Nursing Diagnosis: Pain related to uterine contractions, incision, or breast engorgement
Short term goal: Patient will verbalize a reduction of pain less than 3 according to the pain scale while in my care.
Long term goal: By the end of the postpartum period the patient will be free of pain.
1. Assess pain location, intensity, and level by using pain scale from 0-10.
- Location of pain is necessary for proper treatment. Pain is subjective and must be described by the patient in order to plan effective pharmacological and non pharmacological treatments.
Evaluation: My patient was not experiencing pain at this time. She had a midline episiotomy done and from a scale of 0-10 she said her pain level was a 3. I taught her that if she is in pain to ask for pain medication.
2. Administer pain medications.
- Analgesics inhibits the synthesis of prostaglandins that may serve as mediators or pain, primarily in the CNS. This will provide relief of pain in the post partum period.
Evaluation: My patient was not given any pain meds at this time. She did have an order however for Motrin 600mg po q6h and Percocet i tab prn for pain. If she was experiencing severe pain I would administer these medications.
3. Instruct patient to empty bladder frequently and
completely.
- Emptying the bladder frequently and completely is an effective measure to help reduce the after pains. Afterpains are the result of intermittent uterine contractions. Being my pt was a primipara she did not experience much afterpains because her uterus is able to maintain a contracted state.
Evaluation: My patient voided twice in the morning without any complications. She had told me that she always empties her bladder completely and that she does not hold in her urine.
4. Encourage patient to verbalize pain before it reaches a high level of 4 or more on the pain scale.
- Mild pain is easier to control that when the pain is unbearable. When the patient waits too long to report pain, sensitization may occur and the pain may be so intense that it becomes difficult to relieve the pain. This will lead to more medication required to relieve the pain and severe pain is then more difficult to control
Evaluation: My patient understood that it was normal to be in pain after delivery. She was able to state that she would let me know before the pain gets worse.
5. Teach pt to tighten buttocks before sitting.
- By tightening the buttocks before sitting this reduces the strain on the perineum area which can prevent and reduce pain.
Evaluation: My patient was able to do this whenever she sat on the bed or in a chair. She said that it did reduce the pain slightly even though she did not have that much pain to begin with.
SUMMARY: GOAL MET. PATIENT VERBALIZED A PAIN LEVEL OF 3 OR LESS WITHIN MY CARE.
4. Nursing Diagnosis: Knowledge deficit r/t care of newborn baby.
Short term goal: Patient will verbalize an understanding of postpartum care for baby and herself.
Long term goal: Patient will demonstrate proper care of new born baby as evidence by proper bathing, dressing and feeding techniques.
1. Provide information and teach parents about normal growth and development of a new born; bottle feeding techniques; infant care such as bathing and dressing, care of the umbilical cord; signs and symptoms of illness.
- Knowledge about normal growth and development, care of newborn will increase the chance of successful parenting and will decrease a patient’s anxiety.
Evaluation: My patient was young being only 18 years old. This was her first child therefore I provided her information that she may not be aware of about a new born. Pt stated she took care of her little cousins and had some knowledge already. I provided her with pamplets and handouts on breast feeding and vaginal delivery. I was able to teach her to sponge bathe only until the umbilical cord falls off. The umbilical cord should be cleansed with alcohol daily.
2. Teach mother how to position the baby, the breast and herself when feeding newborn.
- Although breastfeeding is a natural process, breast feeding skills must be learned and practiced. Teaching will decrease anxiety and the problems of ineffective breast feeding.
Evaluation: My patient was able to breast feed using proper techniques. She was able to sit up in bed and the baby was able to latch on the nipple. The baby needs to take the whole nipple into the mouth wide and then bring the baby to the areola. This allows the jaws to compress the milk ducts directly beneath the areola when the baby suckles. The baby’s nose and chin should also touch the breast. I explained to her that there was a lactation nurse available if she had any complications. She was able to breast feed for 20 mins.
3. Teach patient the importance of doing follow up visits with the MD for herself and the baby.
- This ensures that the child is examined by professionals to determine normal growth pattern and to ensure the immunizations are up to date. Breastfeeding babies are looked at 1 week in order to make sure they are breastfeeding effectively and the mother has no complications. Also to see if the baby is ingesting adequate nutrition in order to grow properly.
Evaluation: Patient was able to verbalize an understanding of follow up visit with the physician. She understood that the newborn is to be seen by the physician 6 weeks after discharge.
4. Encourage patient to use hospital as resource for information on newborns such as videos and classes.
- This provides opportunity to answer any questions patient may have that are unclear. This will also allow a better clarification from the health care professionals that the patient may learn and gain knowledge from.
Evaluation: Pt had stated that she would ask the nurse on any classes being offered since she is a new young mother. She also stated that during her pregnancy she did a lot of research and reading about new born care.
SUMMARY: GOAL WAS MET. PT WAS ABLE TO VERBALIZE UNDERSTANDING OF NEWBORN AND BY SHOWING CARE OF THE NEWBORN.
Charles Saikum Nurs 204 Prof Comiskey March 8, 2007
On March 1, 2007 at 6:37am my patient gave birth to her first baby boy at a gestational age of 40.2 weeks. Patient delivered her baby vaginally with a midline episiotomy. The date of her last menstrual period was May 21, 2006 and her EDC was February 28, 2007. My patient is a primigravida therefore her G1 T0 P0 A0 L0. During labor the patient received IV fluids of Lactated Ringers + Pitocin 20 units. Patient also received an epidural anesthesia.
My assessment of 3/2/07 at 8am showed patient to be alert and oriented x3. Skin temperature was warm to touch with capillary refill
Short term goal: Patient will not experience any excessive bleeding & Patient will verbalize an understanding about warning signs of excessive bleeding
Long term goal: Patient’s bleeding will be lighter in color and she will regain her prepregnant state without complications to hemorrhage.
1. Assess and teach pt to palpate uterus for height and firmness and location
- Following birth the fundus has to be firm and should decrease one finger breath a day or more if breastfeeding from the umbilicus. A fundus that is hard tells you the uterus is contracting. If the fundus is above the umbilicus, boggy, blood may be collecting in the …show more content…
uterus and will stop effective contractions leading to hemorrhage.
Evaluation: My patient’s uterus was firm and 1 finger breath below the umbilicus. This is appropriate for her 1st postpartum day. I taught my patient how to feel her own uterus and the early signs of bleeding. She was able to repeat back the information I provided her. My patient is at low risk for injury.
2. Assess patient’s bladder.
- Incomplete emptying of the bladder can lead to bladder distention, which can interfere with the ability of the uterus to contract. If the uterus does not contract properly this can increase the risk of bleeding. A full bladder would also push the fundus to the right.
Evaluation: My patient was up and about voiding twice during my care. She told me that she was not having any trouble or pain urinating. Her urine was clear with tiny drops of blood. Her bladder was not distended.
3. Assess and teach patient to check amount, consistency, and color of lochia.
- The type, amount, and consistency of lochia determine the stage of healing of the placenta site, and a progressive change from bright red at birth to dark red to pink and then to white or clear drainage should occur. Saturation of a pad within 15 to 30 minutes may indicate hemorrhage.
Evaluation: I assessed my patient’s lochia by checking her peripad. Lochia was a moderate amount and dark rubra. She had changed her pad twice during my care. I taught the patient about her lochia and explained to her that increased amount on lochia on the peripads should be reported as it may be an indication of hemorrhaging. Patient stated that she would monitor her peripads daily.
4. Assess vital signs along with labs (H+H).
- A decrease in blood pressure and increase in heart rate may be a sign of hypovolemic shock (bleeding). Her labs will show a decrease in hemoglobin and hematocrit if there is bleeding present. If labs were to be drawn up stat, it would take less than an hour to get the results back. I would also assess her O2 saturation and check her ABG values. This would be able to also show me if she is bleeding.
Evaluation: My patient’s vital signs were within normal limits. Her blood pressure was 123/67, HR 77, Temp 98.1, R 20, and pulse ox 98%. Her H+H were 11.4L and 33.8L. This was slightly low but not a big issue because she is pp day 1 and the normal H+H is 11.5-15.5 and 34.5-45.0.
5. Encourage breast feed.
- This will stimulate the release of oxytocin from the pituitary gland. Oxytocin promotes constriction of the blood vessels and the uterus, thus preventing postpartum hemorrhage promoting involution.
Evaluation: Pt was able to breast feed her son for 20 minutes aiding the release of oxytocin. She did not complain of any pain at this time after breastfeeding.
6. Teach patient to eat foods rich in protein, iron and vitamin C.
- Protein is essential for tissue healing, iron is good for RBC restoration which helps to prevent anemia and vitamin c helps in iron absorption and also aid in tissue healing from the placental site.
Evaluation: Pt ate 100% of her breakfast and lunch. She is 18 years old and has a good appetite being at this age. She verbalizes understanding of how important iron is in her diet and about a good nutrition. She stated that she is very conscious about her nutritional intake and that she would continue to do so.
SUMMARY: GOAL WAS MET AS PATIENT VERBALIZES UNDERSTANDING ABOUT WARNING SIGNS OF EXCESSIVE BLEEDING & THERE WAS NO EVIDENCE OF BLEEDING.
2. Risk for infection (uterine, perineal, incisional, breast, urinary) r/t to childbirth.
Short term goal: Patient will not exhibit any sign of infection as evidence by a temperature < 100 while in my care.
Long term goal: By the end of postpartum period the patient will be free of infection.
1. Assess patient’s perineum for signs of infection using REEDA.
- My patient had a midline episiotomy done therefore any break in the skin and mucus membranes are portals of entry for infectious organisms. Infections cause inflammation characterized by pain, swelling, redness, and heat.
Evaluation: Patient’s perineum did not show any signs of inflammation. It was pink, well approximated, healing nicely with no drainage. Patient did not complain of any pain at this time.
2. Assess patient for generalized signs and symptoms of an infection. (pallor, fatigue, malaise, anorexia, and chills) and teach patient to report any of these signs.
- Prompt detection of an infection is essential as it helps to minimize complications. Early signs will detect immediate treatment.
Evaluation: I informed my patient about the signs and symptoms to be aware of such as fatigue and the chills. Pt was able to understand teaching by repeating back the information. Pt had no generalized signs and symptoms of an infection.
3. Promote perineal care.
- To prevent infection the patient should be informed to cleanse the perineal area daily with warm water and soap. The perineum should also be cleansed after every voiding and bowels using a squeeze bottle filled with warm water. The perineal area should be wiped from front to back to avoid contamination from the anal area.
Evaluation: My patient cleansed her perineal area after voiding twice. She had understood the correct way of keeping her area clean. She also put on a new clean peri pad after being cleaned. My patient was informed about the sitz bath and said that she would try it at home if any pain should occur. At the moment she did not have any pains.
4. Teach patient to change perineal pads frequently.
- Changing perineal pads often will decrease the chance of infection by decreasing the time lochia will be in contact with the perineal area. Lochia is a good medium for bacterial growth and clean pads decrease the risk of infection.
Evaluation: My patient had changed her pad every time she had voided and when they began to feel wet. She said she knew how to frequently change them b/c of the risk of infection. I would teach her to change her pad by removing it from front to back in order to prevent infections. This will help reduce concentrations of pathogens at the vaginal opening.
5. Monitor vital signs
- An elevated temperature, HR, BP, or RR may indicate and infection. Temperature greater than 100.4 F (38C) on two consecutive readings after the first 24hour post delivery may indicate sepsis, UTI, endometritis, mastitis, or other infections. Adaptations of mastitis include chills, headache, flulike muscle aches and malaise, and a warm, reddened painful area of the breast. Adaptations of metritis include bloody, foul smelling, and either scant or profuse discharge, temperature spikes jumping from 101 to 104, tachycardia, and chills.
Evaluation: Patient’s vital signs were within normal limits. Her blood pressure was 123/67, HR 77, Temp 98.1, R 20, and pulse ox 98%. There was no indication of infection noted.
SUMMARY: GOAL MET. PATIENT SHOWED NO SIGNS OR ADAPTATIONS OF AN INFECTION AS EVIDENCE BY BEING A-FEBRILE WHILE IN MY CARE.
3. Nursing Diagnosis: Pain related to uterine contractions, incision, or breast engorgement
Short term goal: Patient will verbalize a reduction of pain less than 3 according to the pain scale while in my care.
Long term goal: By the end of the postpartum period the patient will be free of pain.
1. Assess pain location, intensity, and level by using pain scale from 0-10.
- Location of pain is necessary for proper treatment. Pain is subjective and must be described by the patient in order to plan effective pharmacological and non pharmacological treatments.
Evaluation: My patient was not experiencing pain at this time. She had a midline episiotomy done and from a scale of 0-10 she said her pain level was a 3. I taught her that if she is in pain to ask for pain medication.
2. Administer pain medications.
- Analgesics inhibits the synthesis of prostaglandins that may serve as mediators or pain, primarily in the CNS. This will provide relief of pain in the post partum period.
Evaluation: My patient was not given any pain meds at this time. She did have an order however for Motrin 600mg po q6h and Percocet i tab prn for pain. If she was experiencing severe pain I would administer these medications.
3. Instruct patient to empty bladder frequently and
completely.
- Emptying the bladder frequently and completely is an effective measure to help reduce the after pains. Afterpains are the result of intermittent uterine contractions. Being my pt was a primipara she did not experience much afterpains because her uterus is able to maintain a contracted state.
Evaluation: My patient voided twice in the morning without any complications. She had told me that she always empties her bladder completely and that she does not hold in her urine.
4. Encourage patient to verbalize pain before it reaches a high level of 4 or more on the pain scale.
- Mild pain is easier to control that when the pain is unbearable. When the patient waits too long to report pain, sensitization may occur and the pain may be so intense that it becomes difficult to relieve the pain. This will lead to more medication required to relieve the pain and severe pain is then more difficult to control
Evaluation: My patient understood that it was normal to be in pain after delivery. She was able to state that she would let me know before the pain gets worse.
5. Teach pt to tighten buttocks before sitting.
- By tightening the buttocks before sitting this reduces the strain on the perineum area which can prevent and reduce pain.
Evaluation: My patient was able to do this whenever she sat on the bed or in a chair. She said that it did reduce the pain slightly even though she did not have that much pain to begin with.
SUMMARY: GOAL MET. PATIENT VERBALIZED A PAIN LEVEL OF 3 OR LESS WITHIN MY CARE.
4. Nursing Diagnosis: Knowledge deficit r/t care of newborn baby.
Short term goal: Patient will verbalize an understanding of postpartum care for baby and herself.
Long term goal: Patient will demonstrate proper care of new born baby as evidence by proper bathing, dressing and feeding techniques.
1. Provide information and teach parents about normal growth and development of a new born; bottle feeding techniques; infant care such as bathing and dressing, care of the umbilical cord; signs and symptoms of illness.
- Knowledge about normal growth and development, care of newborn will increase the chance of successful parenting and will decrease a patient’s anxiety.
Evaluation: My patient was young being only 18 years old. This was her first child therefore I provided her information that she may not be aware of about a new born. Pt stated she took care of her little cousins and had some knowledge already. I provided her with pamplets and handouts on breast feeding and vaginal delivery. I was able to teach her to sponge bathe only until the umbilical cord falls off. The umbilical cord should be cleansed with alcohol daily.
2. Teach mother how to position the baby, the breast and herself when feeding newborn.
- Although breastfeeding is a natural process, breast feeding skills must be learned and practiced. Teaching will decrease anxiety and the problems of ineffective breast feeding.
Evaluation: My patient was able to breast feed using proper techniques. She was able to sit up in bed and the baby was able to latch on the nipple. The baby needs to take the whole nipple into the mouth wide and then bring the baby to the areola. This allows the jaws to compress the milk ducts directly beneath the areola when the baby suckles. The baby’s nose and chin should also touch the breast. I explained to her that there was a lactation nurse available if she had any complications. She was able to breast feed for 20 mins.
3. Teach patient the importance of doing follow up visits with the MD for herself and the baby.
- This ensures that the child is examined by professionals to determine normal growth pattern and to ensure the immunizations are up to date. Breastfeeding babies are looked at 1 week in order to make sure they are breastfeeding effectively and the mother has no complications. Also to see if the baby is ingesting adequate nutrition in order to grow properly.
Evaluation: Patient was able to verbalize an understanding of follow up visit with the physician. She understood that the newborn is to be seen by the physician 6 weeks after discharge.
4. Encourage patient to use hospital as resource for information on newborns such as videos and classes.
- This provides opportunity to answer any questions patient may have that are unclear. This will also allow a better clarification from the health care professionals that the patient may learn and gain knowledge from.
Evaluation: Pt had stated that she would ask the nurse on any classes being offered since she is a new young mother. She also stated that during her pregnancy she did a lot of research and reading about new born care.
SUMMARY: GOAL WAS MET. PT WAS ABLE TO VERBALIZE UNDERSTANDING OF NEWBORN AND BY SHOWING CARE OF THE NEWBORN.
Charles Saikum Nurs 204 Prof Comiskey March 8, 2007
On March 1, 2007 at 6:37am my patient gave birth to her first baby boy at a gestational age of 40.2 weeks. Patient delivered her baby vaginally with a midline episiotomy. The date of her last menstrual period was May 21, 2006 and her EDC was February 28, 2007. My patient is a primigravida therefore her G1 T0 P0 A0 L0. During labor the patient received IV fluids of Lactated Ringers + Pitocin 20 units. Patient also received an epidural anesthesia.
My assessment of 3/2/07 at 8am showed patient to be alert and oriented x3. Skin temperature was warm to touch with capillary refill